Provider Demographics
NPI:1386058170
Name:SIKESTON SURGICAL SPECIALIST, LLC
Entity type:Organization
Organization Name:SIKESTON SURGICAL SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-475-8599
Mailing Address - Street 1:1226 LINN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1226 LINN ST
Practice Address - Street 2:SUITE B
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5200
Practice Address - Country:US
Practice Address - Phone:573-475-8599
Practice Address - Fax:573-475-8596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009005897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty