=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356739288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY CLINIC JOPLIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 12/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 CARTER ST
-----------------------------------------------------
City | BERRYVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72616-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-423-5203
-----------------------------------------------------
Fax | 870-423-5178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 MCCLELLAND BLVD
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-627-8962
-----------------------------------------------------
Fax | 417-627-8961
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIVISION VICE PRESIDENT
-----------------------------------------------------
Name | DR. TRACY A GODFREY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 417-627-8962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------