Provider Demographics
NPI:1417216938
Name:MERCY CLINIC JOPLIN LLC
Entity Type:Organization
Organization Name:MERCY CLINIC JOPLIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-556-8962
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-556-8994
Mailing Address - Fax:417-556-8962
Practice Address - Street 1:310 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6743
Practice Address - Country:US
Practice Address - Phone:417-556-8600
Practice Address - Fax:417-556-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDT3607OtherRAIL ROAD MEDICARE
OK200274980NMedicaid
OK200274980NMedicaid