Healthcare Provider Details

I. General information

NPI: 1053441592
Provider Name (Legal Business Name): MERCY CLINIC GERIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 6017-B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 6017-B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6285
  • Fax: 314-251-4173
Mailing address:
  • Phone: 314-251-6285
  • Fax: 314-251-4173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN W. HUBERT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-251-1700