Provider Demographics
NPI:1033159769
Name:MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:HOSPICE OF MERCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-398-6697
Mailing Address - Street 1:701 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-1251
Mailing Address - Country:US
Mailing Address - Phone:319-398-6496
Mailing Address - Fax:319-398-6509
Practice Address - Street 1:315 18TH AVE
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2042
Practice Address - Country:US
Practice Address - Phone:319-398-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-08
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA570036H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
A5240306OtherJOHN DEERE HEALTH PLAN
160079OtherCOVENTRY HEALTH CARE
IA0615120Medicaid
61512OtherWELLMARK BLUE CROSS
61512OtherWELLMARK BLUE CROSS
=========OtherAETNA
=========OtherTRICARE
160079OtherCOVENTRY HEALTH CARE