Provider Demographics
NPI:1447355383
Name:SURGICAL ASSOCIATES OF BLOOMINGTON, ILL,LTD
Entity type:Organization
Organization Name:SURGICAL ASSOCIATES OF BLOOMINGTON, ILL,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-663-4351
Mailing Address - Street 1:1404 EASTLAND DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:309-663-4351
Mailing Address - Fax:309-663-8359
Practice Address - Street 1:1404 EASTLAND DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:309-663-4351
Practice Address - Fax:309-663-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL777460Medicare ID - Type Unspecified