Provider Demographics
NPI:1992706295
Name:NOVAMED SURGERY CENTER OF ST. JOSEPH, LLC
Entity type:Organization
Organization Name:NOVAMED SURGERY CENTER OF ST. JOSEPH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP OF THE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MACOMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-664-4100
Mailing Address - Street 1:1700 E HIGGINS RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5621
Mailing Address - Country:US
Mailing Address - Phone:847-296-5700
Mailing Address - Fax:847-296-5990
Practice Address - Street 1:3201 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1504
Practice Address - Country:US
Practice Address - Phone:816-279-0079
Practice Address - Fax:816-364-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119-2261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9004187Medicare ID - Type UnspecifiedPROVIDER NUMBER