1033352885 NPI number — MERCY CLINIC KIDS GI, LLC

Table of content: (NPI 1033352885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033352885 NPI number — MERCY CLINIC KIDS GI, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCY CLINIC KIDS GI, 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:
Provider Other Organization Name Type Code:
6
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:
1033352885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 S NEW BALLAS RD STE Y-G230
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:
63141-8232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-251-5550
Provider Business Mailing Address Fax Number:
314-251-5552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 S NEW BALLAS RD
Provider Second Line Business Practice Location Address:
SUITE 140-A
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-8232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-996-0006
Provider Business Practice Location Address Fax Number:
314-996-0007
Provider Enumeration Date:
04/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DUNGER
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR - FINANCE
Authorized Official Telephone Number:
314-364-3707

Provider Taxonomy Codes

  • Taxonomy code: 2080P0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 509292504 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com