Healthcare Provider Details

I. General information

NPI: 1770618233
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 NORTH HIGHWAY 5
AVA MO
65608
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 417-683-4045
  • Fax: 417-683-6069
Mailing address:
  • Phone: 417-820-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113969
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number122348
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

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