Basic Information
| Provider Information | |||||||||
| NPI: | 1003081522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EVANSTON SURGICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 ARROWHEAD DR | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | EVANSTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829308752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356139500 | ||||||||
| FaxNumber: | 4356139414 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 ARROWHEAD DR | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | EVANSTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829308752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077891390 | ||||||||
| FaxNumber: | 3077891391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 10/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | O'CONNOR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 3077891390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5079A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1952367450 | 05 | WY | MEDICAID |