Healthcare Provider Details

I. General information

NPI: 1962405803
Provider Name (Legal Business Name): MID RIVERS AMBULATORY SURGERY CENTER LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 VETERANS MEMORIAL PKWY STE 100
SAINT PETERS MO
63376-1680
US

IV. Provider business mailing address

5401 VETERANS MEMORIAL PKWY STE 100
SAINT PETERS MO
63376-1680
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-0906
  • Fax: 636-928-9288
Mailing address:
  • Phone: 636-441-0906
  • Fax: 636-928-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number175
License Number StateMO

VIII. Authorized Official

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