Organization
NORTHEAST MISSOURI AMBULATORY SURGERY CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MATTHEW JOHNSON (ADMINISTRATOR)
(573) 406-1301
Entity
Organization
Contact information
Practice address
98 MEDICAL DRIVE, HANNIBAL, MO 63401
(573) 406-1301
(573) 406-0511
Mailing address
PO BOX 511, HANNIBAL, MO 63401-0511
(573) 406-1301
(573) 406-0511
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
108
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
143365
BCBS PROVIDER ID
MO
01
—
431607
HEALTHLINK PROVIDER ID
MO
01
—
490004674
RAILROAD MEDICARE
MO
05
—
505073205
—
MO
Enumeration date
06/16/2005
Last updated
10/21/2010
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