MEDICARE: ST CHARLES ORTHOPAEDIC SURGERY ASSOCIATES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician		MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	134766	OTHER	MO	BLUE CROSS BLUE SHIELD
2	370199300	OTHER		DOL

General Provider Information

NPI Number	:	1649273723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CHARLES ORTHOPAEDIC SURGERY ASSOCIATES INC.

Provider Business Mailing Address
First Line	:	9323 PHOENIX VILLAGE PKWY
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-4281
Country	:	US
Telephone Number	:	636-561-5030
Fax Number	:	636-561-5033

Provider Business Practice Location Address
First Line	:	400 1ST CAPITOL DR
Second Line	:	STE 100
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2881
Country	:	US
Telephone Number	:	636-946-7050
Fax Number	:	636-946-3368

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. SUZANN CROWDER
Credential	:
Telephone Number	:	636-946-7050

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	07/21/2022

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