Healthcare Provider Details

I. General information

NPI: 1447472519
Provider Name (Legal Business Name): MIDWEST SPECIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 WATERBURY FALLS DR
O FALLON MO
63368-2215
US

IV. Provider business mailing address

830 WATERBURY FALLS DR
O FALLON MO
63368-2215
US

V. Phone/Fax

Practice location:
  • Phone: 636-730-3000
  • Fax:
Mailing address:
  • Phone: 636-730-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number111635
License Number StateMO

VIII. Authorized Official

Name: DR. TONY E SUDEKUM
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 636-730-3000