MEDICARE: MERCY CLINIC NEUROLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician		MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DO0017	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053479188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY CLINIC NEUROLOGY, LLC

Provider Business Mailing Address
First Line	:	621 S NEW BALLAS RD
Second Line	:	SUITE 6005-B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-6075
Fax Number	:	314-251-6634

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD
Second Line	:	SUITE 6005-B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-6075
Fax Number	:	314-251-6634

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR - FINANCE
Name	:	KERRY DUNGER
Credential	:
Telephone Number	:	314-364-3707

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	04/28/2025

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