=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780764829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVAMED SURGERY CENTER OF ST PETERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 03/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 PIPER HILL DR SUITE 101
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-928-1670
-----------------------------------------------------
Fax | 636-928-3792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 PIPER HILL DR SUITE 101
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-928-1670
-----------------------------------------------------
Fax | 636-928-3792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER AND AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENNIFER BOYD BALDOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-234-5935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 197-0
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------