Provider Demographics
NPI:1710982699
Name:NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-406-1301
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0511
Mailing Address - Country:US
Mailing Address - Phone:573-406-1301
Mailing Address - Fax:573-406-0511
Practice Address - Street 1:98 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-406-1301
Practice Address - Fax:573-406-0511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431607OtherHEALTHLINK PROVIDER ID
MO490004674OtherRAILROAD MEDICARE
MO505073205Medicaid
MO143365OtherBCBS PROVIDER ID
MO505073205Medicaid
MO490004674OtherRAILROAD MEDICARE