Healthcare Provider Details

I. General information

NPI: 1508813627
Provider Name (Legal Business Name): FOUR STATES SURGERY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W 32ND ST STE 201
JOPLIN MO
64804-1512
US

IV. Provider business mailing address

1531 EAST BRADFORD PARKWAY STE 100
SPRINGFIELD MO
65804-6539
US

V. Phone/Fax

Practice location:
  • Phone: 417-206-7900
  • Fax: 417-206-3871
Mailing address:
  • Phone: 417-887-3900
  • Fax: 417-823-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number157-1
License Number StateMO

VIII. Authorized Official

Name: MINDY RANDLES
Title or Position: DIRECTOR OF REV CYCLE
Credential:
Phone: 417-887-3900