Provider Demographics
NPI:1235493776
Name:MERCY CLINIC EAST COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC EAST COMMUNITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMMUNITY PRESIDENT - CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:CIARAMITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-525-1785
Mailing Address - Street 1:125 N OLD HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:BOURBON
Mailing Address - State:MO
Mailing Address - Zip Code:65441-6298
Mailing Address - Country:US
Mailing Address - Phone:573-679-2006
Mailing Address - Fax:
Practice Address - Street 1:125 N OLD HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:MO
Practice Address - Zip Code:65441-6298
Practice Address - Country:US
Practice Address - Phone:573-679-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-29
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596407106Medicaid