Provider Demographics
NPI:1104899939
Name:MOTHER OF MERCY
Entity type:Organization
Organization Name:MOTHER OF MERCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-845-2195
Mailing Address - Street 1:PO BOX 676
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MN
Mailing Address - Zip Code:56307-0676
Mailing Address - Country:US
Mailing Address - Phone:320-845-2195
Mailing Address - Fax:320-845-7092
Practice Address - Street 1:230 CHURCH AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MN
Practice Address - Zip Code:56307-0676
Practice Address - Country:US
Practice Address - Phone:320-845-2195
Practice Address - Fax:320-845-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN222043100314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9699MOOtherBLUE CROSS / BLUE SHIELD
MN23788OtherMN SALES TAX EXEMPT NUMBE
MN222043100Medicaid
MN245339Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER