Provider Demographics
NPI:1891012878
Name:CENTRAL MISSOURI SURGERY LLC
Entity Type:Organization
Organization Name:CENTRAL MISSOURI SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SUPPES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-876-1630
Mailing Address - Street 1:401 KEENE ST
Mailing Address - Street 2:THE BOONE CLINIC BUILDING
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6625
Mailing Address - Country:US
Mailing Address - Phone:573-876-1630
Mailing Address - Fax:576-876-1665
Practice Address - Street 1:401 KEENE ST
Practice Address - Street 2:THE BOONE CLINIC BUILDING
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6625
Practice Address - Country:US
Practice Address - Phone:573-876-1630
Practice Address - Fax:576-876-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018694208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty