Provider Demographics
NPI:1730119421
Name:MERCY CLINIC ADULT CRITICAL CARE, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC ADULT CRITICAL CARE, LLC
Other - Org Name:ST. JOHN'S MERCY ADULT CRITICAL CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT, MERCY HOSPITAL ST. LOUIS
Authorized Official - Prefix:
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 1:615 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:314-251-6486
Mailing Address - Fax:314-251-4155
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 4006-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6486
Practice Address - Fax:314-251-4155
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HOSPITALS EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505997106Medicaid
MO505997106Medicaid