Provider Demographics
NPI:1801928593
Name:MERCY MEDICAL CENTER
Entity type:Organization
Organization Name:MERCY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE 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:701-774-7401
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:701-774-7401
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:701-774-7401
Practice Address - Fax:701-774-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5052A103T00000X, 1041C0700X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11684Medicaid
ND711002OtherBLUE SHIELD OF ND
ND11684Medicaid