Provider Demographics
NPI:1467128819
Name:BLOOMINGTON ADVANCED SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:BLOOMINGTON ADVANCED SURGERY CENTER, LLC
Other - Org Name:BLOOMINGTON ADVANCED SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-455-1064
Mailing Address - Street 1:445 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5004
Practice Address - Country:US
Practice Address - Phone:708-275-7799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical