Provider Demographics
NPI:1720194624
Name:MERCY MEDICAL CENTER
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:CHI ST ALEXIUS HEALTH WILLISTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-OPERATIONAL FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:RUARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-774-7400
Mailing Address - Street 1:1301 15TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3821
Mailing Address - Country:US
Mailing Address - Phone:701-774-7400
Mailing Address - Fax:701-774-7479
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7400
Practice Address - Fax:701-774-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5052A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000142001OtherBLUE CROSS OF ND
MT402272Medicaid
ND13671Medicaid
ND13671Medicaid