Healthcare Provider Details

I. General information

NPI: 1184804197
Provider Name (Legal Business Name): MISSOURI PODIATRIC SURGICARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST SUITE 228
WASHINGTON MO
63090-3135
US

IV. Provider business mailing address

851 E 5TH ST SUITE 228
WASHINGTON MO
63090-3135
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-0018
  • Fax: 636-239-0081
Mailing address:
  • Phone: 636-239-0018
  • Fax: 636-239-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number000689
License Number StateMO

VIII. Authorized Official

Name: JOHN M DAILEY
Title or Position: PRESIDENT
Credential: DPM, MBA
Phone: 636-239-0018