Healthcare Provider Details

I. General information

NPI: 1164545315
Provider Name (Legal Business Name): SPECIALTY SURGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 FALLING LEAF CT
COLUMBIA MO
65201-3579
US

IV. Provider business mailing address

3115 FALLING LEAF CT
COLUMBIA MO
65201-3579
US

V. Phone/Fax

Practice location:
  • Phone: 573-449-5000
  • Fax: 573-449-5010
Mailing address:
  • Phone: 573-449-5000
  • Fax: 573-449-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMDR7H73
License Number StateMO

VIII. Authorized Official

Name: DR. MATTHEW J CONCANNON
Title or Position: OWNER
Credential: M.D.
Phone: 573-449-5000