MEDICARE: FOUR STATES SURGERY CENTER, PC

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	157-1	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508813627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUR STATES SURGERY CENTER, PC

Provider Business Mailing Address
First Line	:	1531 EAST BRADFORD PARKWAY STE 100
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-6539
Country	:	US
Telephone Number	:	417-887-3900
Fax Number	:	417-823-2894

Provider Business Practice Location Address
First Line	:	1905 W 32ND ST STE 201
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64804-1512
Country	:	US
Telephone Number	:	417-206-7900
Fax Number	:	417-206-3871

Authorized Official
Title or Position	:	DIRECTOR OF REV CYCLE
Name	:	MINDY RANDLES
Credential	:
Telephone Number	:	417-887-3900

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	02/27/2024

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Directions to “FOUR STATES SURGERY CENTER, PC ” Practice Location

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