1104137876 NPI number — MERCY CLINIC-SPRINGFIELD COMMUNITIES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104137876 NPI number — MERCY CLINIC-SPRINGFIELD COMMUNITIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY CLINIC-SPRINGFIELD COMMUNITIES
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:
MERCY CLINIC FAMILY MEDICINE-SHELL KNOB
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:
1104137876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505164
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-820-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22361 OAK RIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELL KNOB
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65747-7822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-858-3731
Provider Business Practice Location Address Fax Number:
417-858-2562
Provider Enumeration Date:
06/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
STANGELAND
Authorized Official First Name:
STUART
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
SENIOR VICE PRESIDENT, COO
Authorized Official Telephone Number:
417-820-6556

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1104137876 . This is a "RURAL HEALTH MEDICAID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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