Provider Demographics
NPI:1801852520
Name:ADVANCED HEALTHCARE SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:ADVANCED HEALTHCARE SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:2002 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3967
Mailing Address - Country:US
Mailing Address - Phone:573-778-0020
Mailing Address - Fax:573-778-1647
Practice Address - Street 1:2002 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3967
Practice Address - Country:US
Practice Address - Phone:573-778-9209
Practice Address - Fax:573-778-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123-2261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506063007Medicaid
MO5271560001Medicare NSC
MO000040060Medicare PIN