Provider Demographics
NPI:1740245901
Name:ST. LOUIS SURGICAL CENTER, LC
Entity Type:Organization
Organization Name:ST. LOUIS SURGICAL CENTER, LC
Other - Org Name:ST. LOUIS SURGICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:760 OFFICE PKWY
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7105
Mailing Address - Country:US
Mailing Address - Phone:314-995-4700
Mailing Address - Fax:314-995-4701
Practice Address - Street 1:760 OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7105
Practice Address - Country:US
Practice Address - Phone:314-995-4700
Practice Address - Fax:314-995-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO151-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000040083Medicare PIN