Basic Information
| Provider Information | |||||||||
| NPI: | 1255373601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTERFIELD AMBULATORY SURGERY CENTER LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHESTERFIELD SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17050 BAXTER RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630051422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365370122 | ||||||||
| FaxNumber: | 6365370480 | ||||||||
| Practice Location | |||||||||
| Address1: | 17050 BAXTER RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630051422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365370122 | ||||||||
| FaxNumber: | 6365370480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARTSHORN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3148002017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 232-5 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 610832100 | 01 | MO | DEPT. OF LABOR | OTHER | 196128 | 01 | MO | GHP | OTHER | 509077202 | 05 | MO | MEDICAID | P00338546 | 01 | MO | RAILROAD MEDICARE | OTHER | 26D1023601 | 01 | MO | CLIA | OTHER |