Basic Information
| Provider Information | |||||||||
| NPI: | 1578511051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCYCARE MANAGEMENT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 786 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524060786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193694505 | ||||||||
| FaxNumber: | 3193694677 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 8TH ST SE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524012143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193694505 | ||||||||
| FaxNumber: | 3193694677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 02/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIPPER | ||||||||
| AuthorizedOfficialFirstName: | TEDD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3193694505 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0201558 | 05 | IA | MEDICAID |