Provider Demographics
NPI:1811028723
Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Other - Org Name:MERCY CLINIC FAMILY MEDICINE - ROLLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF PHYSICIAN OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVAGNOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-2705
Mailing Address - Street 1:645 MARYVILLE CENTRE DR FL 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5855
Mailing Address - Country:US
Mailing Address - Phone:417-820-7133
Mailing Address - Fax:417-820-0586
Practice Address - Street 1:1605 MARTIN SPRINGS DR STE 210
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3028
Practice Address - Country:US
Practice Address - Phone:573-458-6350
Practice Address - Fax:573-458-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5474207Q00000X
MO261QR1300X
MO064070363LF0000X
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
MO595684804Medicaid
MO595684804Medicaid