1710982699 NPI number — NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC

Table of content: (NPI 1710982699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710982699 NPI number — NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710982699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 511
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANNIBAL
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63401-0511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-406-1301
Provider Business Mailing Address Fax Number:
573-406-0511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANNIBAL
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-406-1301
Provider Business Practice Location Address Fax Number:
573-406-0511
Provider Enumeration Date:
06/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
573-406-1301

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  108 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431607 . This is a "HEALTHLINK PROVIDER ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 490004674 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 505073205 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143365 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".