Provider Demographics
NPI:1477698009
Name:MANCHESTER AMBULATORY SURGERY CENTER LP
Entity Type:Organization
Organization Name:MANCHESTER AMBULATORY SURGERY CENTER LP
Other - Org Name:MANCHESTER SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER OF GENERAL PARTNER COMPANY
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:O
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-713-3514
Mailing Address - Street 1:1040 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-775-2264
Mailing Address - Fax:314-775-2271
Practice Address - Street 1:1040 OLD DES PERES RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1865
Practice Address - Country:US
Practice Address - Phone:314-775-2264
Practice Address - Fax:314-775-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO163-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO716779OtherHEALTHLINK
MO199232OtherANTHEM BC/BS
MOP00286053OtherRR MEDICARE
MO507403707Medicaid
MO613137600OtherDOL FECA
MO242333OtherGROUP HEALTH PLAN
MO716779OtherHEALTHLINK