Healthcare Provider Details

I. General information

NPI: 1396796595
Provider Name (Legal Business Name): MASON RIDGE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N OUTER 40 SUITE 100
SAINT LOUIS MO
63141-8635
US

IV. Provider business mailing address

12855 N OUTER 40 SUITE 100
SAINT LOUIS MO
63141-8635
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-7150
  • Fax: 314-878-3051
Mailing address:
  • Phone: 314-878-7150
  • Fax: 314-878-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number180-0
License Number StateMO

VIII. Authorized Official

Name: MR. CHRISTOPHER ROTHROCK
Title or Position: PRESIDENT
Credential: MD
Phone: 314-878-7150