Provider Demographics
NPI:1679700173
Name:MERCY MEDICAL CENTER-CENTERVILLE
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER-CENTERVILLE
Other - Org Name:CENTERVILLE MEDICAL CLINIC-MERCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-437-3413
Mailing Address - Street 1:19876 ST. JOSEPH'S DRIVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544
Mailing Address - Country:US
Mailing Address - Phone:641-856-8684
Mailing Address - Fax:
Practice Address - Street 1:19876 ST. JOSEPH'S DRIVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544
Practice Address - Country:US
Practice Address - Phone:641-856-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB1441OtherPTAN