Provider Demographics
NPI:1497314181
Name:OPHTHALMOLOGY SURGERY CENTER OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:OPHTHALMOLOGY SURGERY CENTER OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOVACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-634-2980
Mailing Address - Street 1:1300 N ARLINGTON HEIGHTS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-3128
Mailing Address - Country:US
Mailing Address - Phone:630-634-2980
Mailing Address - Fax:630-625-8116
Practice Address - Street 1:1300 N ARLINGTON HEIGHTS RD STE 150
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-3128
Practice Address - Country:US
Practice Address - Phone:630-634-2980
Practice Address - Fax:630-625-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL248002884OtherAMBULATORY SURGICAL CENTER LICENSE