Basic Information
| Provider Information | |||||||||
| NPI: | 1457497513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMENS HEALTH & SURGICAL CENTER MDS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 BRIANNA BLVD | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653012285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608261381 | ||||||||
| FaxNumber: | 6608273001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAN DYKE | ||||||||
| AuthorizedOfficialFirstName: | ELMER | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6608261381 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200437408 | 05 | MO | MEDICAID |