Provider Demographics
NPI:1346252210
Name:PHYSICIANS SURGERY CENTER AT DEPAUL LLC
Entity Type:Organization
Organization Name:PHYSICIANS SURGERY CENTER AT DEPAUL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-907-7907
Mailing Address - Street 1:12266 DEPAUL DRIVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044
Mailing Address - Country:US
Mailing Address - Phone:314-291-7500
Mailing Address - Fax:314-291-7501
Practice Address - Street 1:12266 DEPAUL DRIVE
Practice Address - Street 2:SUITE 10
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-291-7500
Practice Address - Fax:314-291-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical