Provider Demographics
NPI:1720123425
Name:MERCY HEALTH SYSTEM CORPORATION
Entity type:Organization
Organization Name:MERCY HEALTH SYSTEM CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNPHY-ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-757-3126
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6000
Mailing Address - Fax:
Practice Address - Street 1:2000 LAKE AVE
Practice Address - Street 2:ROOM 1423, 1210, 1083, 1047, 1291
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-6009
Practice Address - Country:US
Practice Address - Phone:815-337-1560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310800332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5632221OtherBCBSIL ORTHOTIC
14D0962058OtherCLIA #
IL5632221OtherBCBSIL ORTHOTIC
IL=========006Medicaid
IL0903300041Medicare Oscar/Certification