Provider Demographics
NPI:1376612572
Name:MERCY CLINIC CHILDREN'S CRITICAL CARE, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC CHILDREN'S CRITICAL CARE, LLC
Other - Org Name:ST. JOHN'S MERCY PEDIATRIC CRITICAL CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT, MERCY HOSPITAL ST. LOUIS
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-251-1932
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 6009-B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6598
Mailing Address - Fax:314-251-7990
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 6009-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6598
Practice Address - Fax:314-251-7990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HOSPITALS EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty