Provider Demographics
NPI:1508862996
Name:PLASTIC SURGERY CENTER OF ST JOSEPH, INC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTER OF ST JOSEPH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:DE PRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-364-6446
Mailing Address - Street 1:2111 N WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2440
Mailing Address - Country:US
Mailing Address - Phone:816-364-6416
Mailing Address - Fax:816-364-5320
Practice Address - Street 1:2111 N WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2440
Practice Address - Country:US
Practice Address - Phone:816-364-6416
Practice Address - Fax:816-364-5320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO136-0261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO136-0OtherSTATE LICENSE NUMBER
MO509336905Medicaid