Provider Demographics
NPI:1972532620
Name:MERCY CLINIC CHILDREN'S RESPIRATORY AND SLEEP MEDICINE, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC CHILDREN'S RESPIRATORY AND SLEEP MEDICINE, LLC
Other - Org Name:MERCY PEDIATRIC PULMONARY & SLEEP
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 RD
Mailing Address - Street 2:SUITE 382-A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-5880
Mailing Address - Fax:314-251-6088
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 382-A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-5880
Practice Address - Fax:314-251-6088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-02
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504020207Medicaid