Provider Demographics
NPI:1871744235
Name:PHYSICIANS' SURGICAL CENTER LLC
Entity type:Organization
Organization Name:PHYSICIANS' SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:618-346-4100
Mailing Address - Street 1:311 W LINCOLN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-233-7077
Mailing Address - Fax:618-233-2814
Practice Address - Street 1:311 W LINCOLN ST STE 300
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-233-7077
Practice Address - Fax:618-233-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042-006796261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL141055Medicare PIN