Provider Demographics
NPI:1003081522
Name:EVANSTON SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:EVANSTON SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-789-1390
Mailing Address - Street 1:196 ARROWHEAD DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-8752
Mailing Address - Country:US
Mailing Address - Phone:435-613-9500
Mailing Address - Fax:435-613-9414
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:307-789-1390
Practice Address - Fax:307-789-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5079A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1952367450Medicaid
WY1952367450Medicaid
WYF33771Medicare UPIN