Basic Information
Provider Information | |||||||||
NPI: | 1366515504 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERSIDE AMBULATORY SURGERY CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE ENDOSCOPY & COLONOSCOPY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 VILLAGE SQ | ||||||||
Address2: |   | ||||||||
City: | HAZELWOOD | ||||||||
State: | MO | ||||||||
PostalCode: | 630421820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143738931 | ||||||||
FaxNumber: | 3143738935 | ||||||||
Practice Location | |||||||||
Address1: | 100 VILLAGE SQ | ||||||||
Address2: |   | ||||||||
City: | HAZELWOOD | ||||||||
State: | MO | ||||||||
PostalCode: | 630421820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3143738931 | ||||||||
FaxNumber: | 3143738935 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 06/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORAN | ||||||||
AuthorizedOfficialFirstName: | JENETHA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICARE AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 9727633893 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | P00240669 | 01 | MO | RAILROAD MEDICARE | OTHER | 192544 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 504453606 | 05 | MO |   | MEDICAID | P00240669 | 01 | MO | RR MEDICARE | OTHER |