1770582264 NPI number — ILLIANA SURGERY & MEDICAL CENTER, LLC

Table of content: (NPI 1770582264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770582264 NPI number — ILLIANA SURGERY & MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLIANA SURGERY & MEDICAL CENTER, LLC
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:
6
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:
1770582264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 SUPERIOR AVE
Provider Second Line Business Mailing Address:
ATTN: MANAGED CARE
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-641-3051
Provider Business Mailing Address Fax Number:
219-641-4186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 US HIGHWAY 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHERERVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46375-2892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-865-7986
Provider Business Practice Location Address Fax Number:
219-865-7992
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
VIJAY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
219-922-4200

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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