Healthcare Provider Details

I. General information

NPI: 1871667378
Provider Name (Legal Business Name): MERCY MEDICAL CENTER, DBA MERCY HEALTH PARTNERS SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

IV. Provider business mailing address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-7470
  • Fax: 701-774-7479
Mailing address:
  • Phone: 701-774-7470
  • Fax: 701-774-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number3888
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10618
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number3132
License Number StateND

VIII. Authorized Official

Name: KERRY S. MONSON
Title or Position: VP FINANCE AND CFO
Credential:
Phone: 701-774-7408