Provider Demographics
NPI:1114923513
Name:MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:HALL PERRINE CANCER CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
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:319-398-6343
Mailing Address - Fax:319-862-1398
Practice Address - Street 1:701 10TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-398-6343
Practice Address - Fax:319-862-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1406333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127514OtherPK
IA1114923513Medicaid