MEDICARE: MERCY CLINIC SPRINGFIELD COMMUNITIES

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	207Q00000X	Family Medicine Physician	E1025	AR

Other Identifiers

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

General Provider Information

NPI Number	:	1538195508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERCY CLINIC SPRINGFIELD COMMUNITIES

Provider Business Mailing Address
First Line	:	PO BOX 505164
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-5164
Country	:	US
Telephone Number	:	417-829-4620
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PARK DR
Second Line	:	SUITE C
City	:	HOLIDAY ISLAND
State	:	AR
Zip	:	72631-9216
Country	:	US
Telephone Number	:	479-363-9174
Fax Number	:	479-363-9175

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT/COO
Name	:	MR. STUART G. STANGELAND
Credential	:
Telephone Number	:	417-820-6556

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	10/10/2013

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Practice Location Address:

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1720209588 — DR. RENE CHARLES DUFFOURC III M.D.
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Practice Location Address:

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Practice Location Address:

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