Healthcare Provider Details

I. General information

NPI: 1770616781
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 CITY ROUTE 66
ST. ROBERT MO
65584
US

IV. Provider business mailing address

608 OLD ROUTE 66
SAINT ROBERT MO
65584-3730
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-5100
  • Fax: 573-336-3118
Mailing address:
  • Phone: 573-336-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number095237
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2003017261
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VII. Legacy identifiers

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

# 1
Identifier593363005
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: WILLIAM ROBERTS
Title or Position: CFO
Credential:
Phone: 417-820-7363