Provider Demographics
NPI:1558506204
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY CRYSTAL LAKE MEDICAL CENTER SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR 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 1:415 E CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6248
Practice Address - Country:US
Practice Address - Phone:815-356-7494
Practice Address - Fax:815-356-7541
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCYROCKFORD HEALTH SYSTEM CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-10
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310-800332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========016Medicaid
IL=========016Medicaid
IL214660Medicare Oscar/Certification