Basic Information
| Provider Information | |||||||||
| NPI: | 1174615710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COUNTY SURGICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1209 | ||||||||
| Address2: | |||||||||
| City: | MARYLAND HEIGHTS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630430209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144322580 | ||||||||
| FaxNumber: | 3144320223 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | SUITE 137A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145254740 | ||||||||
| FaxNumber: | 3145254741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARCIAK | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3144322580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R6D37 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DG2303 | 01 | RAILROAD MEDICARE | OTHER | 509350609 | 05 | MO | MEDICAID |