Healthcare Provider Details

I. General information

NPI: 1003110792
Provider Name (Legal Business Name): CREVE COEUR SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N NEW BALLAS CT SUITE 100
CREVE COEUR MO
63141-7134
US

IV. Provider business mailing address

845 N NEW BALLAS CT SUITE 100
CREVE COEUR MO
63141-7134
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-7100
  • Fax:
Mailing address:
  • Phone: 314-872-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number110-9
License Number StateMO

VIII. Authorized Official

Name: DR. JAMES P. EMMANUEL
Title or Position: BOARD MEMBER
Credential: MD
Phone: 314-997-1777