Healthcare Provider Details

I. General information

NPI: 1396871745
Provider Name (Legal Business Name): MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 19 SOUTH
EMINENCE MO
65466
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 573-226-5401
  • Fax: 573-226-3011
Mailing address:
  • Phone: 417-820-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7838
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number112033
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: CHIEF OPERATING OFFICER
Credential:
Phone: 417-820-6556