Basic Information
| Provider Information | |||||||||
| NPI: | 1154321404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HOSPITAL OF FRANCISCAN SISTERS | ||||||||
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| OtherOrganizationName: | MERCY HOSPITAL ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | OELWEIN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506622447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192836000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | COMEAU | ||||||||
| AuthorizedOfficialFirstName: | PERRY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9524429770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 105345 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 67M83ME | 01 | MN | BLUE CROSS MN CC SYST | OTHER | 0101972 | 05 | IA | MEDICAID |