Basic Information
| Provider Information | |||||||||
| NPI: | 1508813627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR STATES SURGERY CENTER, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 W 32ND STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172067900 | ||||||||
| FaxNumber: | 4172063871 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 W 32ND STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172067900 | ||||||||
| FaxNumber: | 4172063871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | LACEY | ||||||||
| AuthorizedOfficialFirstName: | HUGH | ||||||||
| AuthorizedOfficialMiddleName: | LAKE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4176242111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 157-1 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 504769902 | 05 | MO | MEDICAID | 67868614-01 | 05 | KS | MEDICAID | M4120R05 | 05 | OK | MEDICAID |