Healthcare Provider Details

I. General information

NPI: 1720458813
Provider Name (Legal Business Name): BEL CLAIR AMBULATORY SURGICAL TREATMENT CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W LINCOLN ST
BELLEVILLE IL
62220-1921
US

IV. Provider business mailing address

325 W LINCOLN ST
BELLEVILLE IL
62220-1921
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-2299
  • Fax: 618-235-2556
Mailing address:
  • Phone: 618-235-2299
  • Fax: 618-235-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. DAVID RUSSELL HORACE
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-235-2299