Provider Demographics
NPI:1235598954
Name:BROWN BOULEVARD SURGICAL SUITES
Entity Type:Organization
Organization Name:BROWN BOULEVARD SURGICAL SUITES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-932-7242
Mailing Address - Street 1:461 BROWN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:461 BROWN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2322
Practice Address - Country:US
Practice Address - Phone:815-932-7242
Practice Address - Fax:815-932-7307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain