Provider Demographics
NPI:1598727463
Name:CAPE GIRARDEAU OUTPATIENT SURGERY CENTER
Entity Type:Organization
Organization Name:CAPE GIRARDEAU OUTPATIENT SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGERY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:573-335-9175
Mailing Address - Street 1:1429 N MOUNT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2171
Mailing Address - Country:US
Mailing Address - Phone:573-335-9175
Mailing Address - Fax:573-334-3390
Practice Address - Street 1:1429 N MOUNT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:573-335-9175
Practice Address - Fax:573-334-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO53-12261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28OtherBLUECROSS BLUESHIELD
MO107822OtherGROUP HEALTH PLAN
MO1525586OtherUMWA
MO052418OtherHEALTH ALLIANCE
MO241640OtherHEALTHLINK
MO107822OtherGROUP HEALTH PLAN
IL=========001Medicaid