MEDICARE: ST LOUIS SPECIALTY SURGICAL CENTER LLC

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	367500000X	Certified Registered Nurse Anesthetist	2014001570	MO

General Provider Information

NPI Number	:	1962958389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST LOUIS SPECIALTY SURGICAL CENTER LLC

Provider Business Mailing Address
First Line	:	1028 S KIRKWOOD RD
Second Line	:
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-7222
Country	:	US
Telephone Number	:	314-394-2950
Fax Number	:	314-394-2953

Provider Business Practice Location Address
First Line	:	1028 S KIRKWOOD RD
Second Line	:
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-7222
Country	:	US
Telephone Number	:	314-394-2950
Fax Number	:	314-394-2953

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DAVID RUSSELL HORACE
Credential	:
Telephone Number	:	618-973-8740

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	08/26/2016

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