=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255373601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESTERFIELD AMBULATORY SURGERY CENTER LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17050 BAXTER RD STE 110
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-537-0122
-----------------------------------------------------
Fax | 636-537-0480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17050 BAXTER RD STE 110
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-537-0122
-----------------------------------------------------
Fax | 636-537-0480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | CHRISTOPHER HARTSHORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-800-2017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 232-5
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------