Provider Demographics
NPI:1033352885
Name:MERCY CLINIC KIDS GI, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC KIDS GI, LLC
Other - Org Name:ST. JOHN'S MERCY KIDS GI, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-215-1700
Mailing Address - Street 1:621 S NEW BALLAS RD STE Y-G230
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-5550
Mailing Address - Fax:314-251-5552
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 140-A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-996-0006
Practice Address - Fax:314-996-0007
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-09
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509292504Medicaid