Basic Information
| Provider Information | |||||||||
| NPI: | 1841235108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CLINIC ADULT HOSPITALISTS - ST. LOUIS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JOHN'S MERCY HOSPITALIST | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 3016-B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
| FaxNumber: | 3142514564 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 3016-B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
| FaxNumber: | 3142514564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 05/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, MERCY HOSPITAL ST. LOUIS | ||||||||
| AuthorizedOfficialTelephone: | 3142511932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HOSPITALS EAST COMMUNITIES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 505240002 | 05 | MO | MEDICAID |