1205810553 NPI number — ORTHOPAEDIC ASC OF SPRINGFIELD LLC

Table of content: (NPI 1205810553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205810553 NPI number — ORTHOPAEDIC ASC OF SPRINGFIELD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPAEDIC ASC OF SPRINGFIELD 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:
SPRINGFIELD SURGICAL SPECIALIST ASC
Provider Other Organization Name Type Code:
3
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:
1205810553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3045 S NATIONAL AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-4247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-447-3910
Provider Business Mailing Address Fax Number:
447-882-5716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3045 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-4247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-447-3910
Provider Business Practice Location Address Fax Number:
417-882-5716
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICAL SERVICES
Authorized Official Telephone Number:
417-447-3910

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  190-0 , 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)





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