Provider Demographics
NPI:1053479188
Name:MERCY CLINIC NEUROLOGY, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC NEUROLOGY, LLC
Other - Org Name:MERCY NEUROLOGY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
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 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 6005-B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6075
Mailing Address - Fax:314-251-6634
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 6005-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6075
Practice Address - Fax:314-251-6634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053479188Medicaid
MODO0017OtherRAILROAD MEDICARE
MOMA4200Medicare PIN
MO000015210Medicare PIN