Provider Demographics
NPI:1609905637
Name:PETERSON SURGICENTER ANESTHESIA SERVICES SC
Entity Type:Organization
Organization Name:PETERSON SURGICENTER ANESTHESIA SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:I
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-508-9800
Mailing Address - Street 1:2320 W PETERSON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-5242
Mailing Address - Country:US
Mailing Address - Phone:773-508-9800
Mailing Address - Fax:773-508-1796
Practice Address - Street 1:2300 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-5203
Practice Address - Country:US
Practice Address - Phone:773-508-9000
Practice Address - Fax:773-508-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18804Medicare UPIN
IL211943Medicare ID - Type Unspecified