Provider Demographics
NPI:1104857523
Name:SURGERY CENTER OF ST. JOSEPH, LLC
Entity Type:Organization
Organization Name:SURGERY CENTER OF ST. JOSEPH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-279-0079
Mailing Address - Street 1:3201 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1504
Mailing Address - Country:US
Mailing Address - Phone:816-279-0079
Mailing Address - Fax:816-901-0403
Practice Address - Street 1:3201 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1504
Practice Address - Country:US
Practice Address - Phone:816-279-0079
Practice Address - Fax:816-364-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119-3261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502343502Medicaid
MO26C0001012OtherMEDICARE SUPPLIER
MO502343502Medicaid