Healthcare Provider Details

I. General information

NPI: 1891759569
Provider Name (Legal Business Name): ST JOSEPH CENTER FOR OUTPATIENT SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 FREDERICK AVE
SAINT JOSEPH MO
64506-3238
US

IV. Provider business mailing address

4510 FREDERICK AVE
SAINT JOSEPH MO
64506-3238
US

V. Phone/Fax

Practice location:
  • Phone: 816-364-9992
  • Fax: 816-364-9996
Mailing address:
  • Phone: 816-364-9992
  • Fax: 816-364-9996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1332
License Number StateMO

VIII. Authorized Official

Name: ALICIA EDWARDS
Title or Position: ADMINISTRATOR
Credential:
Phone: 816-364-9992