Provider Demographics
NPI:1275648438
Name:OLIVE SURGICAL GROUP, LTD.
Entity Type:Organization
Organization Name:OLIVE SURGICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-699-9818
Mailing Address - Street 1:11605 STUDT AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7052
Mailing Address - Country:US
Mailing Address - Phone:314-699-9818
Mailing Address - Fax:314-699-9868
Practice Address - Street 1:11605 STUDT AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7052
Practice Address - Country:US
Practice Address - Phone:314-699-9818
Practice Address - Fax:314-699-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014674Medicare ID - Type UnspecifiedMEDICAL PRACTICE
MO5547670001Medicare NSC