Provider Demographics
NPI:1902113046
Name:MISSOURI CENTER FOR ORTHOPEDICS AND ADVANCED SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:MISSOURI CENTER FOR ORTHOPEDICS AND ADVANCED SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:IRVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-567-5850
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 5015-B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-567-5850
Mailing Address - Fax:314-567-9169
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 5015-B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-567-5850
Practice Address - Fax:314-567-9169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty