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General NPI Number Information
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NPI Number | 1194228114
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Entity Type | Organization
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Legal Business Name | MERCYLAND PSYCHIATRY INC
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Dates
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Enumeration Date | 03/15/2018
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Last Update Date | 05/07/2018
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Provider Practice Location Address
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Address Line | 530 W MAIN ST
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City | SUN PRAIRIE
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State | WI
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Zip | 53590-3219
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Country | US
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Telephone | 802-399-9114
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Fax | 608-318-2789
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Provider Business Mailing Address
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Address Line | 530 W MAIN ST
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City | SUN PRAIRIE
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State | WI
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Zip | 53590-3219
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Country | US
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Telephone | 802-399-9114
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Fax | 608-318-2789
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. ADEBOWALE MOFIKOYA
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Credential | MD
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Telephone | 802-399-9114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 60574-20
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License Number State | WI
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