Provider Demographics
NPI:1164089124
Name:MERCY CLINIC ILLINOIS, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-1958
Mailing Address - Street 1:1019 VALMEYER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-4123
Mailing Address - Country:US
Mailing Address - Phone:314-543-5244
Mailing Address - Fax:314-543-5248
Practice Address - Street 1:1019 VALMEYER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-4123
Practice Address - Country:US
Practice Address - Phone:314-543-5244
Practice Address - Fax:314-543-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty