Healthcare Provider Details

I. General information

NPI: 1629334222
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR SUITE 240A
ROLLA MO
65401-2931
US

IV. Provider business mailing address

PO BOX 505164
SAINT LOUIS MO
63150-5164
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6310
  • Fax: 573-458-6791
Mailing address:
  • Phone: 417-829-4246
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT03477
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03477
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPENDING
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: STUART STANGELAND
Title or Position: SR. VP/COO
Credential:
Phone: 417-820-3514