Healthcare Provider Details

I. General information

NPI: 1811162696
Provider Name (Legal Business Name): SURGEON'S CHOICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 NEW BALLWIN OAKS DR
BALLWIN MO
63021-4472
US

IV. Provider business mailing address

1144 NEW BALLWIN OAKS DR
BALLWIN MO
63021-4472
US

V. Phone/Fax

Practice location:
  • Phone: 314-458-6717
  • Fax: 636-207-1914
Mailing address:
  • Phone: 314-458-6717
  • Fax: 636-207-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number123589
License Number StateMO

VIII. Authorized Official

Name: MRS. BEVERLY JO MARIEN
Title or Position: PRESIDENT
Credential: CRNFA
Phone: 314-458-6717