Provider Demographics
NPI:1740413988
Name:MERCY HOSPITAL LEBANON
Entity Type:Organization
Organization Name:MERCY HOSPITAL LEBANON
Other - Org Name:MERCY HOSPITAL LEBANON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-7363
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9210
Mailing Address - Country:US
Mailing Address - Phone:417-533-6100
Mailing Address - Fax:417-533-6173
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2931
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:417-533-6173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HOSPITAL LEBANON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-03
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO456-10282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO114678OtherHEALTHLINK COMMERCIAL
MO010492007Medicaid
MO540492006Medicaid
MO=========655360000OtherTRICARE
MO=========655360000OtherTRICARE
MO260059Medicare Oscar/Certification