Provider Demographics
NPI:1598700841
Name:SOUTHWEST SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHWEST SURGERY CENTER, LLC
Other - Org Name:CENTER FOR MINIMALLY INVASIVE SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-399-8427
Mailing Address - Street 1:19110 DARVIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448
Mailing Address - Country:US
Mailing Address - Phone:708-478-8889
Mailing Address - Fax:708-478-8507
Practice Address - Street 1:19110 DARVIN DRIVE
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:708-478-8889
Practice Address - Fax:708-478-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002595261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
203727Medicare ID - Type Unspecified