1861487324 NPI number — DOCTORS PARK SURGERY INC

Table of content: (NPI 1861487324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861487324 NPI number — DOCTORS PARK SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS PARK SURGERY INC
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:
1861487324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 DOCTORS PARK
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE GIRARDEAU
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63703-4928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-334-9606
Provider Business Mailing Address Fax Number:
573-334-9608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 DOCTORS PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-4928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-334-9606
Provider Business Practice Location Address Fax Number:
573-334-9608
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
DARIN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
573-334-9606

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  4616 , 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: 1048868 . This is a "FIRST HEALTH PROVIDER #" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 114023 . This is a "HEALTHLINK PROVIDER ID #" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 490001288 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 501627400 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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