Basic Information
| Provider Information | |||||||||
| NPI: | 1497706626 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICAGO PROSTATE CANCER SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DUPAGE MEDICAL GROUP SURGERY CENTER, WESTMONT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 PASQUINELLI DR | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306542515 | ||||||||
| FaxNumber: | 6306542516 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 PASQUINELLI DR | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306542515 | ||||||||
| FaxNumber: | 6306542516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | TEMPLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6304567211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.