Provider Demographics
NPI:1497720882
Name:THE ST LOUIS MO ORTHOPAEDIC ASC LLC
Entity Type:Organization
Organization Name:THE ST LOUIS MO ORTHOPAEDIC ASC LLC
Other - Org Name:DES PERES SQUARE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1050 OLD DES PERES RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1873
Mailing Address - Country:US
Mailing Address - Phone:314-569-2918
Mailing Address - Fax:314-569-9473
Practice Address - Street 1:1050 OLD DES PERES RD
Practice Address - Street 2:SUITE 150
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1873
Practice Address - Country:US
Practice Address - Phone:314-569-2918
Practice Address - Fax:314-569-9473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO171-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149879OtherBLUE CROSS BLUE SHIELD
MO611789400OtherUS DEPT OF LABOR
MOTRICAREOther260042667
MO490005580OtherRAILROAD MEDICARE
MO149879OtherBLUE CROSS BLUE SHIELD
MO490005580OtherRAILROAD MEDICARE