Provider Demographics
NPI:1164857397
Name:MERCY CLINIC EAST COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC EAST COMMUNITIES
Other - Org Name:MERCY CLINIC CONVENIENT CARE
Other - Org Type:Other 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:314-251-6000
Mailing Address - Street 1:16555 MANCHESTER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1220
Mailing Address - Country:US
Mailing Address - Phone:636-405-3155
Mailing Address - Fax:636-405-3162
Practice Address - Street 1:16555 MANCHESTER RD STE 110
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1220
Practice Address - Country:US
Practice Address - Phone:636-405-3155
Practice Address - Fax:636-405-3162
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164857397Medicaid