Basic Information
| Provider Information | |||||||||
| NPI: | 1952437675 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY CLINIC SPRINGFIELD COMMUNITIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MERCY CLINIC FAMILY MEDICINE-BRANSON WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 MARYVILLE CENTRE DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178207133 | ||||||||
| FaxNumber: | 4178200586 | ||||||||
| Practice Location | |||||||||
| Address1: | 18598 BUSINESS 13 | ||||||||
| Address2: | |||||||||
| City: | BRANSON WEST | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172728497 | ||||||||
| FaxNumber: | 4172728496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | CAVAGNOL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PHYSICIAN OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4178202705 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R2D64 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 095436 | MO | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 595778606 | 05 | MO | MEDICAID |