Healthcare Provider Details

I. General information

NPI: 1053759704
Provider Name (Legal Business Name): MERCY ACO PROVIDER SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

625 S NEW BALLAS RD SUITE 7020
SAINT LOUIS MO
63141-8253
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-1376
  • Fax:
Mailing address:
  • Phone: 314-251-1376
  • Fax: 314-251-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. SHANNON SOCK
Title or Position: PRESIDENT MERCY ACO
Credential:
Phone: 314-251-6000