Healthcare Provider Details

I. General information

NPI: 1154318517
Provider Name (Legal Business Name): CREVE COEUR SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N NEW BALLAS CT SUITE 100
CREVE COEUR MO
63141-7148
US

IV. Provider business mailing address

845 NORTH NEW BALLAS COURT SUITE 100
CREVE COEUR MO
63141-7148
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-7100
  • Fax: 314-872-0929
Mailing address:
  • Phone: 314-872-7100
  • Fax: 314-872-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number110-4
License Number StateMO

VIII. Authorized Official

Name: MRS. CAROLYN HOLLOWOOD
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 314-872-7100