Provider Demographics
NPI:1912037433
Name:MERCY CLINIC BURN AND PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC BURN AND PLASTIC SURGERY, LLC
Other - Org Name:MERCY BURN & PLASTIC SURGERY
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 1:621 S. NEW BALLAS ROAD
Mailing Address - Street 2:SUITE 7003-B
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8275
Mailing Address - Country:US
Mailing Address - Phone:314-251-5570
Mailing Address - Fax:314-251-5571
Practice Address - Street 1:621 S. NEW BALLAS ROAD
Practice Address - Street 2:SUITE 7003-B
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8275
Practice Address - Country:US
Practice Address - Phone:314-251-5570
Practice Address - Fax:314-251-5571
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506063908Medicaid