MEDICARE: BELLEVILLE SURGICAL CENTER LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1275599086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLEVILLE SURGICAL CENTER LTD

Provider Business Mailing Address
First Line	:	28 N 64TH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 N 64TH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3808
Country	:	US
Telephone Number	:	618-398-5705
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KIMBERLY WOOD
Credential	:
Telephone Number	:	828-236-3027

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	08/31/2007

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