| Mercy Clinic Neurology, Llc | |
|
621 S New Ballas Rd Suite 6005-b Saint Louis MO 63141-8232 | |
| (314) 251-6075 | |
| (314) 251-6634 |
| Full Name | Mercy Clinic Neurology, Llc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 621 S New Ballas Rd, Saint Louis, Missouri |
| Authorized Official Name and Position | John W. Hubert (PRESIDENT) |
| Authorized Official Contact | 3142511700 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mercy Clinic Neurology, Llc 621 S New Ballas Rd Suite 6005-b Saint Louis MO 63141-8232 Ph: (314) 251-6075 | Mercy Clinic Neurology, Llc 621 S New Ballas Rd Suite 6005-b Saint Louis MO 63141-8232 Ph: (314) 251-6075 |
| NPI Number | 1053479188 |
|---|---|
| Provider Enumeration Date | 12/04/2006 |
| Last Update Date | 03/04/2016 |
| Medicare PECOS PAC ID | 8729183967 |
|---|---|
| Medicare Enrollment ID | O20070418000103 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053479188 | NPI | - | NPPES |
| 1053479188 | Medicaid | MO | |
| DO0017 | Other | MO | RAILROAD MEDICARE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | (Missouri) | Primary |
| Provider Name | Kyeong P Lee |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1770511271 PECOS PAC ID: 8820900970 Enrollment ID: I20031105000644 |
| Provider Name | Ksenija Kos |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1265454987 PECOS PAC ID: 2961305529 Enrollment ID: I20040130000283 |
| Provider Name | William R Logan |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1750311395 PECOS PAC ID: 4789575085 Enrollment ID: I20040324000993 |
| Provider Name | Venkat K Chintapally Rao |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1891844338 PECOS PAC ID: 0244333961 Enrollment ID: I20070316000169 |
| Provider Name | Mark Tullman |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1629082375 PECOS PAC ID: 5092708859 Enrollment ID: I20110803000184 |
| Provider Name | Richard A Head |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1427097781 PECOS PAC ID: 7810972734 Enrollment ID: I20120206000427 |
| Provider Name | Tariq Alam |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1144419144 PECOS PAC ID: 3870746399 Enrollment ID: I20130114000132 |
| Provider Name | Patricia Schrader |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1689022089 PECOS PAC ID: 8022308592 Enrollment ID: I20160613001126 |
| Provider Name | Allison E Miller |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1538677497 PECOS PAC ID: 9830453646 Enrollment ID: I20180502002514 |
| Provider Name | Kalen R Dionne |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1841672441 PECOS PAC ID: 7618281304 Enrollment ID: I20190730000577 |
| Provider Name | Mohamed M Alwan |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1538542634 PECOS PAC ID: 8820390297 Enrollment ID: I20190731002227 |
| Provider Name | Souzana Obretenova |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1144634791 PECOS PAC ID: 1951521335 Enrollment ID: I20200722000631 |
| Provider Name | Jeffrey S Calvin |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1750764866 PECOS PAC ID: 3173825551 Enrollment ID: I20200804002733 |
| Provider Name | Fang Bai |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1639564776 PECOS PAC ID: 3577872878 Enrollment ID: I20200909000395 |
| Provider Name | Yasser Kabbani |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1982050142 PECOS PAC ID: 5698066736 Enrollment ID: I20210721003110 |
| Provider Name | Nathaniel Wachter |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1922492123 PECOS PAC ID: 8224336946 Enrollment ID: I20210816000788 |
| Provider Name | Divya Sivakumar |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1528419587 PECOS PAC ID: 5092000851 Enrollment ID: I20211210002430 |
| Provider Name | Rachel Barnholtz |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1568116820 PECOS PAC ID: 6103219365 Enrollment ID: I20220210001401 |
| Provider Name | Sara Renee Kootman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1710686894 PECOS PAC ID: 7810356896 Enrollment ID: I20230710000261 |
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