Healthcare Provider Details
I. General information
NPI: 1528060704
Provider Name (Legal Business Name): CMMP SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 06/01/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1705 CHRISTY DR STE 100
JEFFERSON CITY MO
65101-5195
US
IV. Provider business mailing address
1705 CHRISTY DR STE 100
JEFFERSON CITY MO
65101-5195
US
V. Phone/Fax
- Phone: 573-635-7022
- Fax: 573-659-5443
- Phone: 573-635-7022
- Fax: 573-659-5443
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 261QA1903X |
| Taxonomy | Ambulatory Surgical Clinic/Center |
| License Number | 95-6 |
| License Number State | MO |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 537147 |
| Identifier Type | OTHER |
| Identifier State | MO |
| Identifier Issuer | HEALTHLINK PROV NUMBER |
| # 2 | |
| Identifier | 6800140 |
| Identifier Type | OTHER |
| Identifier State | MO |
| Identifier Issuer | UNITED HLTH CARE PROV NUM |
| # 3 | |
| Identifier | 37 |
| Identifier Type | OTHER |
| Identifier State | MO |
| Identifier Issuer | BCBS OF MO PROV NUMBER |
VIII. Authorized Official
Name: DR.
CARL
R
DOERHOFF
Title or Position: MAJORITY PHYSICIAN OWNER
Credential: M.D.
Phone: 573-659-5401