Provider Demographics
NPI:1629024930
Name:MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:MERCY MEDICAL PSYCH 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:52403-1251
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:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-398-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA570036H273R00000X, 276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
6S079OtherWELLMARK BLUE CROSS
IA0600791Medicaid
160079OtherCOVENTRY HEALTH CARE
A5240306OtherJOHN DEERE HEALTH PLAN
A5240306OtherJOHN DEERE HEALTH PLAN
IA0600791Medicaid
=========OtherGREAT-WEST HEALTHCARE
160079OtherCOVENTRY HEALTH CARE