Provider Demographics
NPI:1124029384
Name:LGH-A/GOLF ASTC, LLC
Entity Type:Organization
Organization Name:LGH-A/GOLF ASTC, LLC
Other - Org Name:GOLF SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-321-6698
Mailing Address - Street 1:8901 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6850
Mailing Address - Country:US
Mailing Address - Phone:847-299-2273
Mailing Address - Fax:847-299-7861
Practice Address - Street 1:8901 GOLF RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016
Practice Address - Country:US
Practice Address - Phone:847-299-2273
Practice Address - Fax:847-299-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002231261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490001093OtherRAILROAD MEDICARE
IL545OtherBLUE CROSS PROVIDER NUMBE
IL490001093OtherRAILROAD MEDICARE
IL545OtherBLUE CROSS PROVIDER NUMBE
IL=========001Medicaid