Provider Demographics
NPI:1528009040
Name:MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:MERCY DIALYSIS UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
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:52403-1292
Mailing Address - Country:US
Mailing Address - Phone:319-398-6011
Mailing Address - Fax:319-398-6509
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:52403-1292
Practice Address - Country:US
Practice Address - Phone:319-398-6011
Practice Address - Fax:319-398-6509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-08
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA570036H261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
A5240306OtherJOHN DEERE HEALTH PLAN
62309OtherWELLMARK BLUE CROSS
IA0600791Medicaid
160079OtherCOVENTRY HEALTH CARE
160079OtherCOVENTRY HEALTH CARE
=========OtherAETNA
=========OtherGREAT-WEST HALTHCARE
=========OtherTRICARE