Provider Demographics
NPI:1720458813
Name:BEL CLAIR AMBULATORY SURGICAL TREATMENT CENTER, LTD
Entity Type:Organization
Organization Name:BEL CLAIR AMBULATORY SURGICAL TREATMENT CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:HORACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-235-2299
Mailing Address - Street 1:325 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1921
Mailing Address - Country:US
Mailing Address - Phone:618-235-2299
Mailing Address - Fax:618-235-2556
Practice Address - Street 1:325 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1921
Practice Address - Country:US
Practice Address - Phone:618-235-2299
Practice Address - Fax:618-235-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141065OtherMEDICARE PTAN