Provider Demographics
NPI:1063493443
Name:SEDALIA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SEDALIA SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-829-4024
Mailing Address - Street 1:3310 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2111
Mailing Address - Country:US
Mailing Address - Phone:660-829-4024
Mailing Address - Fax:660-829-2971
Practice Address - Street 1:3310 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2111
Practice Address - Country:US
Practice Address - Phone:660-829-4024
Practice Address - Fax:660-829-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO91125019OtherBLUE CROSS BLUE SHIELD
MO43194001265301OtherTRICARE
MO91125019OtherPHP
MO491944012OtherPRIVATE HEALTHCARE SYSTEM
MO506013507Medicaid
MO=========ASCOtherMERCY HEALTH PLAN
MO91125019OtherBLUE CROSS BLUE SHIELD
MO506013507Medicaid