Provider Demographics
NPI:1356309660
Name:ST. EDWARD MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. EDWARD MERCY MEDICAL CENTER
Other - Org Name:MERCY NORTHSIDE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/ CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-314-6100
Mailing Address - Street 1:PO BOX 17000
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-7000
Mailing Address - Country:US
Mailing Address - Phone:479-314-6100
Mailing Address - Fax:479-314-1770
Practice Address - Street 1:3202 N 6TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-4164
Practice Address - Country:US
Practice Address - Phone:479-314-6100
Practice Address - Fax:479-314-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B820OtherBCBS
AR5B820OtherBCBS