Basic Information
| Provider Information | |||||||||
| NPI: | 1700834165 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MERCY FAMILY COUNSELING, MERCY PSYCHIATRIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1824 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524061824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193694505 | ||||||||
| FaxNumber: | 3193694677 | ||||||||
| Practice Location | |||||||||
| Address1: | 5264 COUNCIL ST NE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524022471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193986575 | ||||||||
| FaxNumber: | 3193694673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHARLES | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3193986697 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.