Healthcare Provider Details

I. General information

NPI: 1962534727
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 S MAIN AVE
REPUBLIC MO
65738
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 417-732-5050
  • Fax: 417-732-8061
Mailing address:
  • Phone: 417-820-7133
  • Fax: 417-820-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number107047
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2001029957
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number145564
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: STUART STANGELAND
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 417-820-3873