Provider Demographics
NPI:1346235058
Name:EAST MEQUON SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EAST MEQUON SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-385-4193
Mailing Address - Street 1:PO BOX 909981
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-8981
Mailing Address - Country:US
Mailing Address - Phone:414-352-3341
Mailing Address - Fax:414-247-4588
Practice Address - Street 1:12203 CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3388
Practice Address - Country:US
Practice Address - Phone:262-387-8383
Practice Address - Fax:262-387-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41913600Medicaid