Provider Demographics
NPI:1629105770
Name:C. REX WITHERSPOON SURGERY CENTER INC
Entity Type:Organization
Organization Name:C. REX WITHERSPOON SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CASC
Authorized Official - Phone:417-447-2482
Mailing Address - Street 1:1103 E MONTCLAIR ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5076
Mailing Address - Country:US
Mailing Address - Phone:417-447-2482
Mailing Address - Fax:417-447-2596
Practice Address - Street 1:1103 E MONTCLAIR ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5076
Practice Address - Country:US
Practice Address - Phone:417-447-2482
Practice Address - Fax:417-447-2596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO148-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507189207Medicaid
MO00040081Medicare ID - Type Unspecified