Provider Demographics
NPI:1154318517
Name:CREVE COEUR SURGERY CENTER LLC
Entity type:Organization
Organization Name:CREVE COEUR SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:314-872-7100
Mailing Address - Street 1:845 NORTH NEW BALLAS COURT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7148
Mailing Address - Country:US
Mailing Address - Phone:314-872-7100
Mailing Address - Fax:314-872-0929
Practice Address - Street 1:845 N NEW BALLAS CT
Practice Address - Street 2:SUITE 100
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7148
Practice Address - Country:US
Practice Address - Phone:314-872-7100
Practice Address - Fax:314-872-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110-4261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO112514OtherBCBS PROVIDER NUMBER
MO=========OtherTAX ID