Provider Demographics
NPI:1184682478
Name:WEST SUBURBAN SURGICAL ASSOCIATES, LTD.
Entity Type:Organization
Organization Name:WEST SUBURBAN SURGICAL ASSOCIATES, LTD.
Other - Org Name:ADVANCED BREAST CARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHARVAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-307-7799
Mailing Address - Street 1:473 W ARMY TRAIL RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2674
Mailing Address - Country:US
Mailing Address - Phone:630-307-7799
Mailing Address - Fax:630-307-2277
Practice Address - Street 1:473 W ARMY TRAIL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2674
Practice Address - Country:US
Practice Address - Phone:630-307-7799
Practice Address - Fax:630-307-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076758208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL786420Medicare PIN