Healthcare Provider Details

I. General information

NPI: 1164089124
Provider Name (Legal Business Name): MERCY CLINIC ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 VALMEYER RD
COLUMBIA IL
62236-4123
US

IV. Provider business mailing address

1019 VALMEYER RD
COLUMBIA IL
62236-4123
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5244
  • Fax: 314-543-5248
Mailing address:
  • Phone: 314-543-5244
  • Fax: 314-543-5248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY DUNGER
Title or Position: EXECUTIVE DIRECTOR - FINANCE
Credential:
Phone: 314-364-3707