Basic Information
Provider Information | |||||||||
NPI: | 1154490779 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY PHYSICIAN ASSOCIATES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCYCARE TAMA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1824 | ||||||||
Address2: |   | ||||||||
City: | CEDAR RAPIDS | ||||||||
State: | IA | ||||||||
PostalCode: | 52406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3193694505 | ||||||||
FaxNumber: | 3193694677 | ||||||||
Practice Location | |||||||||
Address1: | 402 SIEGEL ST | ||||||||
Address2: |   | ||||||||
City: | TAMA | ||||||||
State: | IA | ||||||||
PostalCode: | 523392302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414843333 | ||||||||
FaxNumber: | 3193694677 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2006 | ||||||||
LastUpdateDate: | 04/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STANTON | ||||||||
AuthorizedOfficialFirstName: | ANNETTE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | SR DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3193694512 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.