Provider Demographics
NPI:1821045535
Name:CAPE GIRARDEAU SURGICAL CLINIC, INC.
Entity Type:Organization
Organization Name:CAPE GIRARDEAU SURGICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-334-3074
Mailing Address - Street 1:60 DOCTORS' PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-3074
Mailing Address - Fax:573-334-5554
Practice Address - Street 1:60 DOCTORS' PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-3074
Practice Address - Fax:573-334-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500139001Medicaid
MO000010442Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER