Provider Demographics
NPI:1932176401
Name:MERCY CLINIC HEART AND VASCULAR, LLC
Entity Type:Organization
Organization Name:MERCY CLINIC HEART AND VASCULAR, LLC
Other - Org Name:ST. JOHN'S MERCY HEART AND VASCULAR LLC
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 1:625 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2015
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8253
Mailing Address - Country:US
Mailing Address - Phone:314-251-1700
Mailing Address - Fax:314-251-1701
Practice Address - Street 1:625 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2015
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8253
Practice Address - Country:US
Practice Address - Phone:314-251-1700
Practice Address - Fax:214-251-1701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY CLINIC EAST COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507415701Medicaid
MOMA1160Medicare PIN
MO000014754Medicare ID - Type Unspecified