Provider Demographics
NPI:1619933835
Name:MISSISSIPPI MEDICAL PLAZA, LC
Entity Type:Organization
Organization Name:MISSISSIPPI MEDICAL PLAZA, LC
Other - Org Name:MISSISSIPPI VALLEY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LOHF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-344-6600
Mailing Address - Street 1:3400 DEXTER CT
Mailing Address - Street 2:#200
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3461
Mailing Address - Country:US
Mailing Address - Phone:563-344-6600
Mailing Address - Fax:563-344-6699
Practice Address - Street 1:3400 DEXTER CT
Practice Address - Street 2:#200
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3461
Practice Address - Country:US
Practice Address - Phone:563-344-6600
Practice Address - Fax:563-344-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0143073Medicaid
IA0143073Medicaid
IAI21318Medicare PIN