1255373601 NPI number — CHESTERFIELD AMBULATORY SURGERY CENTER LP

Table of content: (NPI 1255373601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255373601 NPI number — CHESTERFIELD AMBULATORY SURGERY CENTER LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHESTERFIELD AMBULATORY SURGERY CENTER LP
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:
CHESTERFIELD SURGERY CENTER
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:
1255373601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17050 BAXTER RD
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63005-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-537-0122
Provider Business Mailing Address Fax Number:
636-537-0480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17050 BAXTER RD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63005-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-537-0122
Provider Business Practice Location Address Fax Number:
636-537-0480
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTSHORN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
314-800-2017

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  232-5 , 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: 610832100 . This is a "DEPT. OF LABOR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 196128 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 509077202 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00338546 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 26D1023601 . This is a "CLIA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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