Healthcare Provider Details

I. General information

NPI: 1508862996
Provider Name (Legal Business Name): PLASTIC SURGERY CENTER OF ST JOSEPH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 N WOODBINE RD
SAINT JOSEPH MO
64506-2440
US

IV. Provider business mailing address

2111 N WOODBINE RD
SAINT JOSEPH MO
64506-2440
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-6416
  • Fax: 816-364-5320
Mailing address:
  • Phone: 816-364-6416
  • Fax: 816-364-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number136-0
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL D DE PRIEST
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 816-364-6446