Provider Demographics
NPI:1366515504
Name:RIVERSIDE AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:RIVERSIDE AMBULATORY SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICARE AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-2017
Mailing Address - Street 1:100 VILLAGE SQ
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1820
Mailing Address - Country:US
Mailing Address - Phone:314-373-8931
Mailing Address - Fax:314-373-8935
Practice Address - Street 1:100 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1820
Practice Address - Country:US
Practice Address - Phone:314-373-8931
Practice Address - Fax:314-373-8935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00240669OtherRAILROAD MEDICARE
MO192544OtherBLUE CROSS BLUE SHIELD
MOP00240669OtherRR MEDICARE
MO504453606Medicaid
MOP00240669OtherRAILROAD MEDICARE
MOP00240669OtherRAILROAD MEDICARE