Provider Demographics
NPI:1083924294
Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Other - Org Name:MERCY CLINIC-BERRYVILLE-WALMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT, COO
Authorized Official - Prefix:
Authorized Official - First Name:DONN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-6556
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1000 W TRIMBLE AVE
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4603
Practice Address - Country:US
Practice Address - Phone:870-423-4472
Practice Address - Fax:870-423-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01264363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1083924294Medicaid
AR5G709Medicare PIN