Provider Demographics
NPI:1679658710
Name:STADIUM CAMPUS AMBULATORY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:STADIUM CAMPUS AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:WILLS EYE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-440-3152
Mailing Address - Street 1:3340 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-5802
Mailing Address - Country:US
Mailing Address - Phone:215-463-1900
Mailing Address - Fax:
Practice Address - Street 1:3340 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-5802
Practice Address - Country:US
Practice Address - Phone:215-463-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA11381500261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017912500002Medicaid
PA034751Medicare ID - Type Unspecified