Provider Demographics
NPI:1043530538
Name:MERCY CLINIC SURGICAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC SURGICAL SPECIALISTS, LLC
Other - Org Name:MERCY SURGICAL SPECIALISTS
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:314-251-1700
Mailing Address - Street 1:851 E 5TH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3135
Mailing Address - Country:US
Mailing Address - Phone:636-861-7870
Mailing Address - Fax:636-861-7899
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3135
Practice Address - Country:US
Practice Address - Phone:636-861-7870
Practice Address - Fax:636-861-7899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-07
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2536Medicare PIN