Healthcare Provider Details

I. General information

NPI: 1790876027
Provider Name (Legal Business Name): FLORISSANT VALLEY SURGICAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD SUITE 402
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

11125 DUNN RD SUITE 402
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number105535
License Number StateMO

VIII. Authorized Official

Name: DR. MORIN HANSON
Title or Position: OWNER
Credential: M.D.
Phone: 314-741-3400