Provider Demographics
NPI:1093794927
Name:SURGICAL CLINIC INC
Entity type:Organization
Organization Name:SURGICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:636-240-1100
Mailing Address - Street 1:103 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2894
Mailing Address - Country:US
Mailing Address - Phone:636-240-1100
Mailing Address - Fax:636-240-1104
Practice Address - Street 1:103 CHURCH ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2894
Practice Address - Country:US
Practice Address - Phone:636-240-1100
Practice Address - Fax:636-240-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E39560Medicare UPIN
D41719Medicare UPIN