Healthcare Provider Details

I. General information

NPI: 1184962862
Provider Name (Legal Business Name): MERCY CLINTON ANESTHESIA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2013
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N 4TH ST
CLINTON IA
52732-2940
US

IV. Provider business mailing address

400 E 10TH ST
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 563-244-3500
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN J WILLIAMS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 563-244-3530