Organization
PRUETT SURGICAL ASSOCIATES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TRACY J PARCIAK (OFFICE MANAGER)
(314) 432-2580
Entity
Organization
Contact information
Practice address
3009 N BALLAS RD, 132A, SAINT LOUIS, MO 63131-2322
(314) 995-6999
(314) 995-7064
Mailing address
PO BOX 11750, SAINT LOUIS, MO 63105-0550
(314) 432-2580
(314) 432-0223
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
2002008093
MO
174400000X
Specialist
27599
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
142447
GHP/CMR GROUP PROV#
MO
01
—
DA 2337
RR MCR GROUP PROV#
MO
Enumeration date
06/08/2006
Last updated
09/24/2008
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