Healthcare Provider Details

I. General information

NPI: 1417216938
Provider Name (Legal Business Name): MERCY CLINIC JOPLIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 2ND AVE SW
MIAMI OK
74354-6743
US

IV. Provider business mailing address

100 MERCY WAY
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-8600
  • Fax: 417-556-8602
Mailing address:
  • Phone: 417-556-8994
  • Fax: 417-556-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY A GODFREY
Title or Position: PRESIDENT
Credential: MD
Phone: 417-556-8962