Provider Demographics
NPI:1265495824
Name:AMBULATORY SURGERY CENTER OF CENTRALIA, LLC
Entity Type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF CENTRALIA, LLC
Other - Org Name:THE SURGERY CENTER OF CENTRALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UDAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIYANAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-899-9200
Mailing Address - Street 1:1045 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3001
Mailing Address - Country:US
Mailing Address - Phone:618-532-3110
Mailing Address - Fax:618-532-7226
Practice Address - Street 1:1045 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3001
Practice Address - Country:US
Practice Address - Phone:618-532-3110
Practice Address - Fax:618-532-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065384261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
06130323OtherBLUE CROSS BLUE SHIELD
IL036065384Medicaid
CH8278OtherRR MEDICARE
06130323OtherBLUE CROSS BLUE SHIELD