Provider Demographics
NPI:1962958389
Name:ST LOUIS SPECIALTY SURGICAL CENTER LLC
Entity type:Organization
Organization Name:ST LOUIS SPECIALTY SURGICAL CENTER LLC
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:618-973-8740
Mailing Address - Street 1:1028 S KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7222
Mailing Address - Country:US
Mailing Address - Phone:314-394-2950
Mailing Address - Fax:314-394-2953
Practice Address - Street 1:1028 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-7222
Practice Address - Country:US
Practice Address - Phone:314-394-2950
Practice Address - Fax:314-394-2953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014001570367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty