Provider Demographics
NPI:1891759569
Name:ST JOSEPH CENTER FOR OUTPATIENT SURGERY, LLC
Entity Type:Organization
Organization Name:ST JOSEPH CENTER FOR OUTPATIENT SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5935
Mailing Address - Street 1:4510 FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3238
Mailing Address - Country:US
Mailing Address - Phone:816-364-9992
Mailing Address - Fax:816-364-9996
Practice Address - Street 1:4510 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3238
Practice Address - Country:US
Practice Address - Phone:816-364-9992
Practice Address - Fax:816-364-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1332261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO91182018OtherBLUE SHIELD PROVIDER NUMB
MO506121409Medicaid
MO9004208Medicare ID - Type UnspecifiedPROVIDER NUMBER