Provider Demographics
NPI:1871500967
Name:RIVERSIDE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:RIVERSIDE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNES
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:314-373-2063
Mailing Address - Street 1:6829 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5312
Mailing Address - Country:US
Mailing Address - Phone:314-373-2063
Mailing Address - Fax:314-373-2070
Practice Address - Street 1:6829 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5312
Practice Address - Country:US
Practice Address - Phone:314-373-2063
Practice Address - Fax:314-373-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO153-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical