Basic Information
Provider Information | |||||||||
NPI: | 1275545279 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SURGERY CENTER OF COLUMBIA LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 305 N KEENE ST | ||||||||
Address2: | STE 107 | ||||||||
City: | COLUMBIA | ||||||||
State: | MO | ||||||||
PostalCode: | 652016897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5732566272 | ||||||||
FaxNumber: | 5732566304 | ||||||||
Practice Location | |||||||||
Address1: | 305 N KEENE ST | ||||||||
Address2: | STE 107 | ||||||||
City: | COLUMBIA | ||||||||
State: | MO | ||||||||
PostalCode: | 652016897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5732566272 | ||||||||
FaxNumber: | 5732566304 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2006 | ||||||||
LastUpdateDate: | 08/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARTSHORN | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 3148002017 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 149-1 | MO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 507492205 | 05 | MO |   | MEDICAID |