Provider Demographics
NPI:1740226091
Name:MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC SPRINGFIELD COMMUNITIES
Other - Org Name:MERCY CLINIC-FAMILY MEDICINE BERRYVILLE
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:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:207 CARTER ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4303
Practice Address - Country:US
Practice Address - Phone:870-423-6661
Practice Address - Fax:870-423-4374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR6D08207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128620002Medicaid
MO501625800Medicaid
ARCR0464OtherTRAVELERS/RR MEDICARE #
AR5B093Medicare PIN