=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275286643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGERY CENTERS OF MISSOURI
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2022
-----------------------------------------------------
Last Update Date | 02/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12101 WOODCREST EXECUTIVE DR STE 101
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-378-2085
-----------------------------------------------------
Fax | 314-659-8307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 S. SPOEDE RD.
-----------------------------------------------------
City | FRONTENAC
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63131-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-695-8933
-----------------------------------------------------
Fax | 314-659-8307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | WILLIAM DOUGLAS KULA CRAGG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-695-8933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------