Provider Demographics
NPI:1740517341
Name:MERCY CLINIC JOPLIN, LLC
Entity type:Organization
Organization Name:MERCY CLINIC JOPLIN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-556-8962
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 1:805 BARKER DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:KS
Practice Address - Zip Code:67356
Practice Address - Country:US
Practice Address - Phone:620-795-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1740517341OtherKANSAS BLUE CROSS
KS200639810FMedicaid
KS615149202OtherDEPARTMENT OF LABOR (OWCP-DEEOIC)
OK200274980EMedicaid
MO1740517341Medicaid
KS200639810FMedicaid