Healthcare Provider Details

I. General information

NPI: 1972771657
Provider Name (Legal Business Name): MERCY CLINIC SPRINGFIELD COMMUNITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E MAIN ST
WILLOW SPRINGS MO
65793
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 417-469-1820
  • Fax: 417-469-5280
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 Number2009010253
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013019442
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT CAVAGNOL
Title or Position: CHIEF PHYSICIAN OFFICER
Credential:
Phone: 417-820-2705