Healthcare Provider Details

I. General information

NPI: 1104082692
Provider Name (Legal Business Name): OLD TESSON SURGERY CENTER, L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12639 OLD TESSON RD STE 130
SAINT LOUIS MO
63128-2786
US

IV. Provider business mailing address

12639 OLD TESSON RD STE 130
SAINT LOUIS MO
63128-2786
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-0785
  • Fax: 314-667-3629
Mailing address:
  • Phone: 314-729-0785
  • Fax: 314-667-3629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number129-4
License Number StateMO

VIII. Authorized Official

Name: CHRISTOPHER HARTSHORN
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 314-800-2017