MEDICARE: CAPE GIRARDEAU OUTPATIENT SURGERY CENTER

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	53-12	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28	OTHER	MO	BLUECROSS BLUESHIELD
2	107822	OTHER	MO	GROUP HEALTH PLAN
3	1525586	OTHER	MO	UMWA
4	052418	OTHER	MO	HEALTH ALLIANCE
5	241640	OTHER	MO	HEALTHLINK

General Provider Information

NPI Number	:	1598727463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPE GIRARDEAU OUTPATIENT SURGERY CENTER

Provider Business Mailing Address
First Line	:	1429 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2171
Country	:	US
Telephone Number	:	573-335-9175
Fax Number	:	573-334-3390

Provider Business Practice Location Address
First Line	:	1429 N MOUNT AUBURN RD
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-2171
Country	:	US
Telephone Number	:	573-335-9175
Fax Number	:	573-334-3390

Authorized Official
Title or Position	:	SURGERY ADMINISTRATOR
Name	:	SUZIE VICKERY
Credential	:	RN
Telephone Number	:	573-335-9175

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	04/20/2008

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1922078088 — DR. MATTHEW J COLEMAN M.D.
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1477519890 — DR. MICHAEL L GIVENS D.C.
Practice Location Address:

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Directions to “CAPE GIRARDEAU OUTPATIENT SURGERY CENTER ” Practice Location

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