Provider Demographics
NPI:1366183097
Name:SQUARE ONE SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:SQUARE ONE SURGICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CSFA
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:636-346-8182
Mailing Address - Street 1:15524 GOLDEN RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5124
Mailing Address - Country:US
Mailing Address - Phone:636-346-8182
Mailing Address - Fax:
Practice Address - Street 1:15524 GOLDEN RIDGE CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5124
Practice Address - Country:US
Practice Address - Phone:636-346-8182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710444872OtherNPPES