Provider Demographics
NPI:1528192416
Name:MERCY CLINIC CARDIOVASCULAR AND THORACIC SURGERY, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC CARDIOVASCULAR AND THORACIC SURGERY, LLC
Other - Org Name:ST. JOHN'S MERCY CARDIVASCULAR & THORACIC SURGERY ASSOCIATES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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:314-251-1700
Mailing Address - Street 1:625 S. NEW BALLAS ROAD
Mailing Address - Street 2:SUITE R-7040
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-6970
Mailing Address - Fax:314-251-1053
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3135
Practice Address - Country:US
Practice Address - Phone:314-251-6970
Practice Address - Fax:314-251-1053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015247Medicare PIN