Provider Demographics
NPI:1124069877
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:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:G
Authorized Official - Last Name:STANGELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-6556
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:613 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-5013
Practice Address - Country:US
Practice Address - Phone:870-423-4240
Practice Address - Fax:870-423-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0693207V00000X
ARR8E81207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500147301Medicaid
AR150959002Medicaid
AR150959002Medicaid