Provider Demographics
NPI:1437231446
Name:ILLINI SURGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:ILLINI SURGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:RSA
Authorized Official - Phone:630-795-1855
Mailing Address - Street 1:PO BOX 5306
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-0306
Mailing Address - Country:US
Mailing Address - Phone:630-795-1855
Mailing Address - Fax:630-795-1844
Practice Address - Street 1:6809 ARMSTRONG CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1526
Practice Address - Country:US
Practice Address - Phone:630-795-1855
Practice Address - Fax:630-795-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty