1215066956 NPI number — MERCY CLINIC SPRINGFIELD COMMUNITIES

Table of content: (NPI 1215066956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215066956 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-AGAPE FAMILY MEDICINE
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:
1215066956
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 MARYVILLE CENTRE DR FL 3
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:
63141-5855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-820-7133
Provider Business Mailing Address Fax Number:
417-820-0586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-533-6500
Provider Business Practice Location Address Fax Number:
417-533-6555
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAVAGNOL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PHYSICIAN OFFICER
Authorized Official Telephone Number:
417-820-2705

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  105131 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 2002018364 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 595979907 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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