Healthcare Provider Details

I. General information

NPI: 1073642765
Provider Name (Legal Business Name): MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HOSPITAL DR SUITE 225
LEBANON MO
65536
US

IV. Provider business mailing address

645 MARYVILLE CENTRE DR FL 3
SAINT LOUIS MO
63141-5855
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6710
  • Fax: 417-533-6719
Mailing address:
  • Phone: 417-820-7133
  • Fax: 417-820-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number114220
License Number StateMO
# 2
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