Healthcare Provider Details

I. General information

NPI: 1801852520
Provider Name (Legal Business Name): ADVANCED HEALTHCARE SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 KANELL BLVD
POPLAR BLUFF MO
63901-3967
US

IV. Provider business mailing address

2002 KANELL BLVD
POPLAR BLUFF MO
63901-3967
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-9209
  • Fax: 573-778-1647
Mailing address:
  • Phone: 573-778-0020
  • Fax: 573-778-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number123-2
License Number StateMO

VIII. Authorized Official

Name: JOHN M HOJA
Title or Position: CHAIRMAN/AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 573-778-0020