Provider Demographics
NPI:1821133133
Name:MASON RIDGE AMBULATORY SURGERY CENTER, LP
Entity Type:Organization
Organization Name:MASON RIDGE AMBULATORY SURGERY CENTER, LP
Other - Org Name:MASON RIDGE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3859
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-878-7150
Mailing Address - Fax:314-878-3051
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-878-7150
Practice Address - Fax:314-878-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO201-7261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204703OtherBLUE CROSS BLUE SHIELD
MO500092309Medicaid
MO000040103Medicare PIN
MO500092309Medicaid