1508813627 NPI number — FOUR STATES SURGERY CENTER, PC

Table of content: (NPI 1508813627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508813627 NPI number — FOUR STATES SURGERY CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR STATES SURGERY CENTER, PC
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:
6
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:
1508813627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1531 EAST BRADFORD PARKWAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-6539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-887-3900
Provider Business Mailing Address Fax Number:
417-823-2894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 W 32ND ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-206-7900
Provider Business Practice Location Address Fax Number:
417-206-3871
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RANDLES
Authorized Official First Name:
MINDY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REV CYCLE
Authorized Official Telephone Number:
417-887-3900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  157-1 , 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: M4120R05 , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 504769902 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 67868614-01 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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