Basic Information
| Provider Information | |||||||||
| NPI: | 1881602357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HOSPITAL JEFFERSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 US HIGHWAY 61 | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630284100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
| FaxNumber: | 6369331136 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 US HIGHWAY 61 | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630284100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
| FaxNumber: | 6369331136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | ECKENFELS | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6369331107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 160-48 | MO | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 010155703 | 05 | MO | MEDICAID |