Provider Demographics
NPI:1487783296
Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Entity type:Organization
Organization Name:MERCY CLINIC-SPRINGFIELD COMMUNITIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:G
Authorized Official - Last Name:STANGELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-3873
Mailing Address - Street 1:645 MARYVILLE CENTRE DR FL 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5855
Mailing Address - Country:US
Mailing Address - Phone:417-820-7133
Mailing Address - Fax:417-820-0586
Practice Address - Street 1:1422 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483
Practice Address - Country:US
Practice Address - Phone:417-967-4445
Practice Address - Fax:417-967-4453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013261207Q00000X
MO130675363LF0000X
MO119291363LF0000X
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO597932607Medicaid
MO263839Medicare Oscar/Certification