Provider Demographics
NPI:1215040464
Name:DEERPATH AMBULATORY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:DEERPATH AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:DEERPATH ORTHOPEDIC SURGICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-318-5626
Mailing Address - Street 1:1051 W US ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3349
Mailing Address - Country:US
Mailing Address - Phone:815-318-5666
Mailing Address - Fax:815-318-5676
Practice Address - Street 1:1051 W US ROUTE 6
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450
Practice Address - Country:US
Practice Address - Phone:815-318-5666
Practice Address - Fax:815-318-5676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL209663Medicare ID - Type Unspecified