Provider Demographics
NPI:1891946349
Name:MERCY CLINIC ST. LOUIS CANCER AND BREAST INSTITUTE, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC ST. LOUIS CANCER AND BREAST INSTITUTE, LLC
Other - Org Name:ST LOUIS CANCER AND BREAST INSTITUTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-251-1700
Mailing Address - Street 1:15945 CLAYTON RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2490
Mailing Address - Country:US
Mailing Address - Phone:636-256-5000
Mailing Address - Fax:314-989-1323
Practice Address - Street 1:621 S NEW BALLAS RD STE 260A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8256
Practice Address - Country:US
Practice Address - Phone:314-251-8001
Practice Address - Fax:314-256-5043
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-02
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504721903Medicaid