1720165723 NPI number — SUBURBAN SURGICAL FACILITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720165723 NPI number — SUBURBAN SURGICAL FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN SURGICAL FACILITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720165723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 S WASHINGTON ST
Provider Second Line Business Mailing Address:
STE 22
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60540-6795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-810-0451
Provider Business Mailing Address Fax Number:
877-446-3870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18660 GRAPHIC DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
TINLEY PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60477-6260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-810-0451
Provider Business Practice Location Address Fax Number:
877-446-3870
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIXON
Authorized Official First Name:
ELTON
Authorized Official Middle Name:
WADE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
630-810-0451

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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