Provider Demographics
NPI:1043942378
Name:GREAT CIRCLE
Entity Type:Organization
Organization Name:GREAT CIRCLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:RICKER
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-356-0022
Mailing Address - Street 1:330 N GORE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1600
Mailing Address - Country:US
Mailing Address - Phone:844-424-3577
Mailing Address - Fax:314-919-4876
Practice Address - Street 1:1212 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2720
Practice Address - Country:US
Practice Address - Phone:844-424-3577
Practice Address - Fax:314-919-4876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-27
Last Update Date:2022-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507009603Medicaid