Provider Demographics
NPI:1912020397
Name:ST. JOHN'S MERCY SUPPORT SERVICES
Entity Type:Organization
Organization Name:ST. JOHN'S MERCY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCURRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-628-3423
Mailing Address - Street 1:901 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3127
Mailing Address - Country:US
Mailing Address - Phone:636-239-8000
Mailing Address - Fax:636-239-8890
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8000
Practice Address - Fax:636-239-8890
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HOSPITALS EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-09
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507219806Medicaid
MO000014458Medicare ID - Type Unspecified