Provider Demographics
NPI:1063945434
Name:MERCY MEDICAL HEALTH CENTER
Entity type:Organization
Organization Name:MERCY MEDICAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, NP
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, APRN
Authorized Official - Phone:318-259-1100
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:HODGE
Mailing Address - State:LA
Mailing Address - Zip Code:71247-0070
Mailing Address - Country:US
Mailing Address - Phone:318-259-1100
Mailing Address - Fax:318-259-1333
Practice Address - Street 1:244 BOND ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-5334
Practice Address - Country:US
Practice Address - Phone:318-259-1100
Practice Address - Fax:318-259-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
LAAP05919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2468588Medicaid