Provider Demographics
NPI:1508983784
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY CRYSTAL LAKE OB GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:COOK
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 1:750 E TERRA COTTA AVE
Practice Address - Street 2:STE B
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3621
Practice Address - Country:US
Practice Address - Phone:815-459-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-23
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310800332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0411934OtherCLIA
14D0411934OtherCLIA