Basic Information
| Provider Information | |||||||||
| NPI: | 1821045535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE GIRARDEAU SURGICAL CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 DOCTORS' PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733343074 | ||||||||
| FaxNumber: | 5733345554 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 DOCTORS' PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733343074 | ||||||||
| FaxNumber: | 5733345554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | HOLT | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5733343074 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500139001 | 05 | MO | MEDICAID |