=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255398251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY HEALTH SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 S MUSTANG RD SUITE S
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-749-7099
-----------------------------------------------------
Fax | 405-749-4561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 504438
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63150-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-751-4664
-----------------------------------------------------
Fax | 405-749-4561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | V.P.
-----------------------------------------------------
Name | JEFF JOHNSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-751-4664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------