=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760549000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 15TH AVE W
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-774-7470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 15TH AVE W
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-774-7470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP-OPERATIONAL FINANCE
-----------------------------------------------------
Name | JOSEPH RUARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-774-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QC0050X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 5052
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------