Provider Demographics
NPI:1730486556
Name:ST. EDWARD MERCY CLINIC, INC.
Entity Type:Organization
Organization Name:ST. EDWARD MERCY CLINIC, INC.
Other - Org Name:MERCY CLINIC RIVER VALLEY THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:479-314-6100
Mailing Address - Street 1:PO BOX 11230
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1230
Mailing Address - Country:US
Mailing Address - Phone:479-709-6767
Mailing Address - Fax:479-709-6768
Practice Address - Street 1:3501 WE KNIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6248
Practice Address - Country:US
Practice Address - Phone:479-709-6700
Practice Address - Fax:479-709-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G410OtherBLUE CROSS BLUE SHIELD
OK200199350JMedicaid
ARDR1533OtherRAILROAD MEDICARE
AR5G410OtherBLUE CROSS BLUE SHIELD