Provider Demographics
NPI:1285630160
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 OFFICIAL
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:615-234-5900
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:
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:866-631-7890
Practice Address - Fax:314-838-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO76-9261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505450205Medicaid
490003037OtherRR MEDICARE
MO505450205Medicaid