1053458299 NPI number — ST. JOHN'S MERCY HEALTH SERVICES, LLC

Table of content: (NPI 1053458299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053458299 NPI number — ST. JOHN'S MERCY HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHN'S MERCY HEALTH SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. JOHN'S MERCY MANAGED BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053458299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 DES PERES RD
Provider Second Line Business Mailing Address:
SUITE 200C
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63131-2050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-729-4639
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 DES PERES RD
Provider Second Line Business Practice Location Address:
SUITE 200C
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-729-4639
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FREDERICK
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
314-729-4639

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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