Provider Demographics
NPI:1023383742
Name:MERCY CLINIC CHILDREN'S PALLIATIVE CARE LLC
Entity Type:Organization
Organization Name:MERCY CLINIC CHILDREN'S PALLIATIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-6000
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 6006-B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6299
Mailing Address - Fax:314-251-4450
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 6006-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6299
Practice Address - Fax:314-251-4450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HOSPITALS EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty