Provider Demographics
NPI:1003260100
Name:NOVAMED EYE SURGERY CENTER OF NORTH COUNTY LLC
Entity Type:Organization
Organization Name:NOVAMED EYE SURGERY CENTER OF NORTH COUNTY LLC
Other - Org Name:WOODCREST SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-838-0321
Mailing Address - Fax:314-838-6532
Practice Address - Street 1:12101 WOODCREST EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5047
Practice Address - Country:US
Practice Address - Phone:314-838-0321
Practice Address - Fax:314-838-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6223Medicare PIN