Provider Demographics
NPI:1871094052
Name:MERCY SOUTHERN MISSOURI AMBULATORY SERVICES LLC
Entity type:Organization
Organization Name:MERCY SOUTHERN MISSOURI AMBULATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO-CENTRAL COMMUNITY
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-820-2818
Mailing Address - Street 1:620 S GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3206
Mailing Address - Country:US
Mailing Address - Phone:417-556-8967
Mailing Address - Fax:417-556-8968
Practice Address - Street 1:900 E BATTLEFIELD ST STE 124
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5208
Practice Address - Country:US
Practice Address - Phone:417-556-8967
Practice Address - Fax:417-556-8968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care