Provider Demographics
NPI:1497159024
Name:ADVANCED SURGICAL TECHNOLOGY, LLC
Entity Type:Organization
Organization Name:ADVANCED SURGICAL TECHNOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-969-8317
Mailing Address - Street 1:4200 WILLIAMSON PL STE 1A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6705
Mailing Address - Country:US
Mailing Address - Phone:618-899-9200
Mailing Address - Fax:618-899-9206
Practice Address - Street 1:4200 WILLIAMSON PL STE 1A
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6705
Practice Address - Country:US
Practice Address - Phone:618-899-9200
Practice Address - Fax:618-899-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115674208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty