Basic Information
| Provider Information | |||||||||
| NPI: | 1104933696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST LAKES SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2808 S INGRAM MILL RD | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658044042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178892040 | ||||||||
| FaxNumber: | 4178892041 | ||||||||
| Practice Location | |||||||||
| Address1: | 12499 UNIVERSITY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLIVE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503258281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159745050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | FORMANEK | ||||||||
| AuthorizedOfficialFirstName: | TERI | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5153271555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | NA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0610352 | 05 | IA | MEDICAID | 61026 | 01 | IA | FEDERAL EMPLOYEES HEALTH | OTHER | F252394 | 01 | IA | CARPENTERS DISTRICT COUN | OTHER | F252394 | 01 | IA | CIGNA | OTHER | 61026 | 01 | IA | WELLMARK BCBS | OTHER | F252394 | 01 | IA | MIDLANDS AETNA | OTHER | 61026 | 01 | IA | WELLMARK HEALTH PLANS IA | OTHER |