Basic Information
| Provider Information | |||||||||
| NPI: | 1952949992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST SUBURBAN SURGICAL ASSISTANTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 CHANTICLEER LN | ||||||||
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| City: | HINSDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605215023 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 E BRUSH HILL RD | ||||||||
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| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601265658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3312211000 | ||||||||
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| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOVESHNIKOV | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7733150935 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.