Healthcare Provider Details

I. General information

NPI: 1699802330
Provider Name (Legal Business Name): SUBURBAN SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N. NEW BALLAS RD SUITE 265
SAINT LOUIS MO
63141-6825
US

IV. Provider business mailing address

555 N. NEW BALLAS RD SUITE 265
SAINT LOUIS MO
63141-6825
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-4644
  • Fax: 314-991-4910
Mailing address:
  • Phone: 314-991-4644
  • Fax: 314-991-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA M MOLLOY
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 314-991-4644