Healthcare Provider Details

I. General information

NPI: 1659343093
Provider Name (Legal Business Name): MERCY HOSPITAL OF DEVILS LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 7TH ST NE
DEVILS LAKE ND
58301-2798
US

IV. Provider business mailing address

1031 7TH ST NE
DEVILS LAKE ND
58301-2798
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-2131
  • Fax: 701-662-9651
Mailing address:
  • Phone: 701-662-2131
  • Fax: 701-662-9651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number5012
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QC0050X
TaxonomyCritical Access Hospital Clinic/Center
License Number5012
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number5012A
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number5012
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier001101
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier1454896
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: KURT SARGENT
Title or Position: VP OPERATIONAL FINANCE
Credential:
Phone: 701-237-8064