Basic Information
| Provider Information | |||||||||
| NPI: | 1861487324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS PARK SURGERY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733349606 | ||||||||
| FaxNumber: | 5733349608 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733349606 | ||||||||
| FaxNumber: | 5733349608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | DARIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5733349606 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 4616 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1048868 | 01 | MO | FIRST HEALTH PROVIDER # | OTHER | 114023 | 01 | MO | HEALTHLINK PROVIDER ID # | OTHER | 490001288 | 01 | RAILROAD MEDICARE | OTHER | 501627400 | 05 | MO | MEDICAID | 59 | 01 | MO | BLUE CROSS BLUE SHIELD ID | OTHER |