Provider Demographics
NPI:1669685129
Name:MERCY HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:MERCY OPTIONS BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-971-6752
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
Mailing Address - Country:US
Mailing Address - Phone:608-756-6000
Mailing Address - Fax:
Practice Address - Street 1:903 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2970
Practice Address - Country:US
Practice Address - Phone:608-756-5555
Practice Address - Fax:608-756-0174
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-08
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310-800261Q00000X, 261QA0600X, 261QM0855X, 261QR0400X
WI310800261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43009200Medicaid
WI42180200Medicaid
WI42232800Medicaid
WI42180321Medicaid
WI42180300Medicaid
WI11011426Medicaid
WI42180221Medicaid
WI43171321Medicaid
WI42180300Medicaid