Healthcare Provider Details

I. General information

NPI: 1538195508
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK DR SUITE C
HOLIDAY ISLAND AR
72631-9216
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 479-363-9174
  • Fax: 479-363-9175
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE1025
License Number StateAR

VIII. Authorized Official

Name: MR. STUART G. STANGELAND
Title or Position: SENIOR VICE PRESIDENT/COO
Credential:
Phone: 417-820-6556