Provider Demographics
NPI:1659330751
Name:MERCY HOSPITAL
Entity Type:Organization
Organization Name:MERCY HOSPITAL
Other - Org Name:MERCY HOME CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LES
Authorized Official - Middle Name:
Authorized Official - Last Name:WIETSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-845-1900
Mailing Address - Street 1:570 CHAUTAUQUA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3145
Mailing Address - Country:US
Mailing Address - Phone:701-845-6400
Mailing Address - Fax:701-845-6413
Practice Address - Street 1:243 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2965
Practice Address - Country:US
Practice Address - Phone:701-845-6550
Practice Address - Fax:701-845-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4031A251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND055612Medicaid
ND055612Medicaid