Provider Demographics
NPI:1093768962
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY HOSPITAL JANESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-756-6000
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6000
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310-800225X00000X, 261QP2000X
WI310800261Q00000X, 261QM0855X, 282N00000X, 332B00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11011426Medicaid
WI43009200Medicaid
WI11011400Medicaid
WI43171321Medicaid
WI43009200Medicaid
WI11011426Medicaid
IL=========401 1Medicaid
WICD9551Medicare PIN
=========019OtherBCBSWI FACILITY ID
WI11011400Medicaid