Basic Information
| Provider Information | |||||||||
| NPI: | 1538325931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY CLINIC SPRINGFIELD COMMUNITIES | ||||||||
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| OtherOrganizationName: | SJC-NEUROSURGERY-ROGERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 RIFE MEDICAL LN | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793383270 | ||||||||
| FaxNumber: | 4793383287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | STANGELAND | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 4178203514 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | AR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207T00000X | E5600 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | AR | AR MEDICAID | OTHER |