Provider Demographics
NPI:1922137645
Name:MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type:Organization
Organization Name:MERCY CLINIC SPRINGFIELD COMMUNITIES
Other - Org Name:MERCY CLINIC PEDIATRICS-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
Practice Address - Street 2:SUITE 250
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-458-6363
Practice Address - Fax:573-458-6765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108228208000000X
MO261QR1300X
MO146525363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597380708Medicaid
MO268935Medicare Oscar/Certification