Healthcare Provider Details

I. General information

NPI: 1306042890
Provider Name (Legal Business Name): MERCY CARE MANAGEMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 EDGEWOOD RD SW
CEDAR RAPIDS IA
52404-3258
US

IV. Provider business mailing address

PO BOX 786
CEDAR RAPIDS IA
52406-0786
US

V. Phone/Fax

Practice location:
  • Phone: 319-369-4798
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0794263
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier0794255
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MR. TIMOTHY L CHARLES
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 319-398-6697