Healthcare Provider Details

I. General information

NPI: 1205810553
Provider Name (Legal Business Name): ORTHOPAEDIC ASC OF SPRINGFIELD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 S NATIONAL AVE SUITE 101
SPRINGFIELD MO
65804-4247
US

IV. Provider business mailing address

3045 S NATIONAL AVE SUITE 101
SPRINGFIELD MO
65804-4247
US

V. Phone/Fax

Practice location:
  • Phone: 417-447-3910
  • Fax: 417-882-5716
Mailing address:
  • Phone: 417-447-3910
  • Fax: 447-882-5716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number190-0
License Number StateMO

VIII. Authorized Official

Name: JANE MALONE
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: RN
Phone: 417-447-3910