Provider Demographics
NPI:1194228114
Name:MERCYLAND PSYCHIATRY INC
Entity Type:Organization
Organization Name:MERCYLAND PSYCHIATRY INC
Other - Org Name:MERCYLAND PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEBOWALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFIKOYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-399-9114
Mailing Address - Street 1:530 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3219
Mailing Address - Country:US
Mailing Address - Phone:802-399-9114
Mailing Address - Fax:608-318-2789
Practice Address - Street 1:530 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3219
Practice Address - Country:US
Practice Address - Phone:802-399-9114
Practice Address - Fax:608-318-2789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60574-202084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty