Provider Demographics
NPI:1619192556
Name:SAUK VALLEY SURGICAL, PC
Entity Type:Organization
Organization Name:SAUK VALLEY SURGICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAQUELYNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:NAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:815-288-1052
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-0514
Mailing Address - Country:US
Mailing Address - Phone:815-288-1052
Mailing Address - Fax:815-284-0584
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3083
Practice Address - Country:US
Practice Address - Phone:815-288-1052
Practice Address - Fax:815-284-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082587208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082587Medicaid
IL036082587Medicaid
YY11615Medicare UPIN