Basic Information
| Provider Information | |||||||||
| NPI: | 1043547474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY CLINIC JOPLIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504944 | ||||||||
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| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144666428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 W SYCAMORE ST | ||||||||
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| City: | COLUMBUS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667251276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6204293636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 07/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | GODFREY | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4175568962 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043547474 | 05 | MO | MEDICAID | 200639810B | 05 | KS | MEDICAID | 1043547474 | 01 | KS | KANSAS BLUE CROSS | OTHER |