Provider Demographics
NPI:1174615710
Name:SOUTH COUNTY SURGICAL SERVICES, LLC
Entity type:Organization
Organization Name:SOUTH COUNTY SURGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARCIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0209
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 137A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-525-4740
Practice Address - Fax:314-525-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6D37174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG2303OtherRAILROAD MEDICARE
MO509350609Medicaid
MOC68080Medicare UPIN
MO509350609Medicaid