Provider Demographics
NPI:1033351119
Name:SSM ST CLARE SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:SSM ST CLARE SURGICAL CENTER LLC
Other - Org Name:SSM ST CLARE SURGICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCARVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-889-2040
Mailing Address - Street 1:1055 BOWLES AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2308
Mailing Address - Country:US
Mailing Address - Phone:636-203-9700
Mailing Address - Fax:636-203-9779
Practice Address - Street 1:1055 BOWLES AVE
Practice Address - Street 2:STE 100
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2308
Practice Address - Country:US
Practice Address - Phone:636-203-9700
Practice Address - Fax:636-203-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO229-0261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033351119Medicaid
MOP00846977OtherRAILROAD MEDICARE
MOP00846977OtherRAILROAD MEDICARE
MOP00846977OtherRAILROAD MEDICARE