Basic Information
Provider Information | |||||||||
NPI: | 1598709016 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MERCY CLINIC SPRINGFIELD COMMUNITIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MERCY CLINIC-HEAD & NECK SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2580 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658012580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178294620 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1229 E SEMINOLE ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658042227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178205089 | ||||||||
FaxNumber: | 4178205085 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2006 | ||||||||
LastUpdateDate: | 08/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SORENSEN | ||||||||
AuthorizedOfficialFirstName: | DONN | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/COO | ||||||||
AuthorizedOfficialTelephone: | 4178206556 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 63-10 | MO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 502721400 | 05 | MO |   | MEDICAID | CB9013 | 01 | MO | TRAVELERS/RR MEDICARE # | OTHER |