Basic Information
| Provider Information | |||||||||
| NPI: | 1861470486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORLAND PARK SURGICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9550 WEST 167 STREET | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604675561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084787437 | ||||||||
| FaxNumber: | 7086795356 | ||||||||
| Practice Location | |||||||||
| Address1: | 9550 WEST 167 STREET | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604675561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084787437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | HORSTMANN | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7084787437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 7002553 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 00050131 | 01 | IL | BCBSIL | OTHER |