Healthcare Provider Details

I. General information

NPI: 1619965324
Provider Name (Legal Business Name): ADVANCED SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12607 OLIVE BLVD
SAINT LOUIS MO
63141-6313
US

IV. Provider business mailing address

12607 OLIVE BLVD
SAINT LOUIS MO
63141-6313
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-1610
  • Fax: 314-205-1233
Mailing address:
  • Phone: 314-205-1610
  • Fax: 314-205-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number132-0
License Number StateMO

VIII. Authorized Official

Name: MELINDA SMITH
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 314-205-1610