1407251622 NPI number — MASSAC COUNTY SURGERY CENTER LLC

Table of content: (NPI 1407251622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407251622 NPI number — MASSAC COUNTY SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASSAC COUNTY 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:
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:
1407251622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 S CLIFF AVE
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57104-5355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-444-8207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METROPOLIS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-309-6000
Provider Business Practice Location Address Fax Number:
618-309-6001
Provider Enumeration Date:
10/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF NURSING
Authorized Official Telephone Number:
618-309-6005

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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