=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396748588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY HOSPITAL JEFFERSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 02/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 INDUSTRIAL DR
-----------------------------------------------------
City | FESTUS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63028-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-933-1162
-----------------------------------------------------
Fax | 636-933-1579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 INDUSTRIAL DR
-----------------------------------------------------
City | FESTUS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63028-4134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-933-1162
-----------------------------------------------------
Fax | 636-933-1579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT FINANCE
-----------------------------------------------------
Name | DANIEL ECKENFELS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-525-1483
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 198-20
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------