Healthcare Provider Details

I. General information

NPI: 1104857523
Provider Name (Legal Business Name): SURGERY CENTER OF ST. JOSEPH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 ASHLAND AVE
SAINT JOSEPH MO
64506-1504
US

IV. Provider business mailing address

3201 ASHLAND AVE
SAINT JOSEPH MO
64506-1504
US

V. Phone/Fax

Practice location:
  • Phone: 816-279-0079
  • Fax: 816-364-1100
Mailing address:
  • Phone: 816-279-0079
  • Fax: 816-901-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number119-3
License Number StateMO

VIII. Authorized Official

Name: ANGELA J FRY
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 816-279-0079