Basic Information
| Provider Information | |||||||||
| NPI: | 1023297553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOARDMAN | ||||||||
| AuthorizedOfficialFirstName: | SHEFFIELD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6185495361 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 50935 | 01 | IL | BLUE CROSS OF ILLINOIS | OTHER | 878466 | 01 | HEALTH LINK | OTHER | 014101 | 01 | HEALTH ALLIANCE | OTHER | 328614 | 01 | GROUP HEALTH PLANS | OTHER |