Provider Demographics
NPI:1588667208
Name:BRADFORD PARKWAY SURGERY AND LASER CENTER
Entity Type:Organization
Organization Name:BRADFORD PARKWAY SURGERY AND LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-886-3900
Mailing Address - Street 1:1531 E 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:417-886-3900
Mailing Address - Fax:417-823-2894
Practice Address - Street 1:1531 E BRADFORD PARKWAY STE 120
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6539
Practice Address - Country:US
Practice Address - Phone:417-886-3900
Practice Address - Fax:417-886-0094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118.6261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506002104Medicaid
MO000040057Medicare PIN