Healthcare Provider Details

I. General information

NPI: 1366183097
Provider Name (Legal Business Name): SQUARE ONE SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15524 GOLDEN RIDGE CT
CHESTERFIELD MO
63017-5124
US

IV. Provider business mailing address

15524 GOLDEN RIDGE CT
CHESTERFIELD MO
63017-5124
US

V. Phone/Fax

Practice location:
  • Phone: 636-346-8182
  • Fax:
Mailing address:
  • Phone: 636-346-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ANDREW SHERIDAN
Title or Position: CSFA
Credential: CSFA
Phone: 636-346-8182