1497720882 NPI number — THE ST LOUIS MO ORTHOPAEDIC ASC LLC

Table of content: (NPI 1497720882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497720882 NPI number — THE ST LOUIS MO ORTHOPAEDIC ASC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE ST LOUIS MO ORTHOPAEDIC ASC 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:
DES PERES SQUARE 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:
1497720882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1050 OLD DES PERES RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63131-1873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-569-2918
Provider Business Mailing Address Fax Number:
314-569-9473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 OLD DES PERES RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63131-1873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-569-2918
Provider Business Practice Location Address Fax Number:
314-569-9473
Provider Enumeration Date:
02/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLENDENIN
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  171-1 , 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: 149879 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 611789400 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: TRICARE . This is a "260042667" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 490005580 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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