Healthcare Provider Details

I. General information

NPI: 1770612590
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: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HOSPITAL DR STE 350
LEBANON MO
65536-9253
US

IV. Provider business mailing address

1570 W BATTLEFIELD ST STE 110
SPRINGFIELD MO
65807-4163
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6746
  • Fax: 417-533-6740
Mailing address:
  • Phone: 417-820-7133
  • Fax: 417-820-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123516
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: WILLIAM ROBERTS
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 417-820-7363