MEDICARE: MERCYLAND PSYCHIATRY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	60574-20	WI

General Provider Information

NPI Number	:	1194228114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCYLAND PSYCHIATRY INC

Provider Business Mailing Address
First Line	:	530 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3219
Country	:	US
Telephone Number	:	802-399-9114
Fax Number	:	608-318-2789

Provider Business Practice Location Address
First Line	:	530 W MAIN ST
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-3219
Country	:	US
Telephone Number	:	802-399-9114
Fax Number	:	608-318-2789

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ADEBOWALE MOFIKOYA
Credential	:	MD
Telephone Number	:	802-399-9114

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	05/07/2018

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