Provider Demographics
NPI:1568591295
Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Other - Org Name:MERCY CLINIC FAMILY MEDICINE-HOLLISTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:G
Authorized Official - Last Name:STANGELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-6556
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-820-2000
Mailing Address - Fax:
Practice Address - Street 1:290 CLIFT CT
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-5947
Practice Address - Country:US
Practice Address - Phone:417-336-4355
Practice Address - Fax:417-337-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006039080207Q00000X
MO261QR1300X
MO113864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596090605Medicaid
MO263961Medicare Oscar/Certification