NPIMap

Organization Active NPI

Mercy Medical Services

Doing business as MercyOne Kingsley Family Medicine

  • Rural Health Clinic/Center
  • Kingsley, IA
National Provider Identifier
1790723633
Registry record updated Oct 18, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MERCY MEDICAL SERVICES
Doing business as
MercyOne Kingsley Family Medicine
Practice address
111 S Main St
Kingsley, IA 51028-5021
Phone
(712) 378-2921
Fax
(712) 378-2965
NPI assigned
Jun 3, 2006
Last updated
Oct 18, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 18, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jesica Hanson
Title
VP Finance
Phone
(712) 279-5850

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

111 S Main St
Kingsley, IA 51028-5021

Mailing address

PO Box 328
Sioux City, IA 51102-0328
Phone (712) 279-5830

Other names 1

  • MercyOne Kingsley Family Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030310000014 IA Part A Provider - Rural Health Clinic 5799694063 Practice locations: Kingsley, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1790723633. Details of each certification follow.

Rural health clinic certification: CCN 163846

Legal name
MERCY MEDICAL SERVICES
Doing business as
MERCYONE KINGSLEY FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 26, 1994
Last certification
Sep 22, 2021
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
Sep 23, 1986 in IA
Enrollment address
111 Main St
Kingsley, IA 51028-7725

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Timothy Daugherty Individual W-2 Managing EmployeeVP Operations and Strategy Oct 6, 2018
Antoinette M Pratt Individual Operational/Managerial ControlChain Home Office Administrator May 15, 2013
Maurita Soukup Individual Corporate DirectorBoard Member Jan 1, 2017
Linda Ross Individual Corporate DirectorBoard Member Jan 1, 2020
Robert P Ritz Individual Corporate DirectorBoard Member Jan 1, 2018
Heather Campbell Individual Corporate OfficerSecretary Jan 1, 2020
Michael a Wegner Individual Corporate OfficerTreasurer Jan 15, 2018
Mercy Health Network Inc Organization, Clive, IA Corporation, Non-profit Operational/Managerial Control Mar 1, 2016 100%
Milton D Avery Individual Corporate DirectorBoard Member Jan 1, 2017
Jesica Hanson Individual Corporate OfficerAssistant Treasurer Aug 13, 2019
Operational/Managerial ControlAssistant Treasurer Aug 13, 2019
M. Elizabeth Flannery-Hughes Individual Corporate OfficerPresident Nov 1, 2019
W-2 Managing EmployeePresident Nov 1, 2019
Operational/Managerial ControlPresident Nov 1, 2019
Mercy Health Services-Iowa Corp Organization, Mason City, IA Corporation, For-profit 5% Or Greater Direct Ownership Interest Aug 19, 1998 100%
Trinity Health Corporation Organization, Livonia, MI Corporation, Non-profit 5% Or Greater Indirect Ownership Interest May 1, 2000 100%

Owners & managing parties with NPI records 11

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Hawarden ClinicHawarden, IA, CCN 168503 Rural health clinic 5% Or Greater Direct Ownership Interest (50%)
Operational/Managerial Control		 Aug 3, 2004
Aug 3, 2004

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 215

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 215

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729209600000",
    "number": "1790723633",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 328",
            "city": "SIOUX CITY",
            "state": "IA",
            "postal_code": "511020328",
            "telephone_number": "712-279-5830",
            "fax_number": "712-279-5883"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 S MAIN ST",
            "city": "KINGSLEY",
            "state": "IA",
            "postal_code": "510285021",
            "telephone_number": "712-378-2921",
            "fax_number": "712-378-2965"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MERCY MEDICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-03",
        "last_updated": "2024-10-18",
        "certification_date": "2024-10-18",
        "status": "A",
        "authorized_official_last_name": "HANSON",
        "authorized_official_first_name": "JESICA",
        "authorized_official_title_or_position": "VP FINANCE",
        "authorized_official_telephone_number": "712-279-5850"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MercyOne Kingsley Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kingsley, IA

Sources for this page

Verify at the official NPI Registry.