Provider Demographics
NPI:1871667378
Name:MERCY MEDICAL CENTER, DBA MERCY HEALTH PARTNERS SPECIALTY GROUP
Entity Type:Organization
Organization Name:MERCY MEDICAL CENTER, DBA MERCY HEALTH PARTNERS SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MONSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-774-7408
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:701-774-7470
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:701-774-7470
Practice Address - Fax:701-774-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3132207X00000X
ND3888207X00000X
ND10618208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12754Medicaid
ND711005OtherBCBS OF ND
ND711005OtherBCBS OF ND