Provider Demographics
NPI:1508813627
Name:FOUR STATES SURGERY CENTER, PC
Entity Type:Organization
Organization Name:FOUR STATES SURGERY CENTER, PC
Other - Org Name:FOUR STATES SURGERY CENTER,
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REV CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-887-3900
Mailing Address - Street 1:1531 EAST BRADFORD PARKWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6539
Mailing Address - Country:US
Mailing Address - Phone:417-887-3900
Mailing Address - Fax:417-823-2894
Practice Address - Street 1:1905 W 32ND ST STE 201
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1512
Practice Address - Country:US
Practice Address - Phone:417-206-7900
Practice Address - Fax:417-206-3871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO157-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKM4120R05Medicaid
MO504769902Medicaid
KS67868614-01Medicaid
KS67868614-01Medicaid