Provider Demographics
NPI:1033470745
Name:MERCY CLINIC DERMATOLOGY LLC
Entity Type:Organization
Organization Name:MERCY CLINIC DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
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:314-251-1560
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 597A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-2095
Mailing Address - Fax:314-251-2096
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 597A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-2095
Practice Address - Fax:314-251-2096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033470745Medicaid
MODT7966OtherRAILROAD MEDICARE
MOMA4174Medicare PIN
MODT7966OtherRAILROAD MEDICARE