Provider Demographics
NPI:1710926589
Name:PHYSICIAN SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PHYSICIAN SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-342-2255
Mailing Address - Street 1:PO BOX 1294
Mailing Address - Street 2:1207 NETWORK CENTRE BLVD
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401
Mailing Address - Country:US
Mailing Address - Phone:217-342-2255
Mailing Address - Fax:217-342-2619
Practice Address - Street 1:1500 HIGHWAY 72 EAST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-426-6301
Practice Address - Fax:573-426-6304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00443325OtherRAILROAD MEDICARE
514184OtherHEALTHLINK
168305OtherBCBS
511377OtherHEALTHLINK
514184OtherHEALTHLINK
=========OtherEIN
MO000040056Medicare ID - Type Unspecified
P00443325OtherRAILROAD MEDICARE
825845519Medicare PIN
511377OtherHEALTHLINK
=========654010000OtherRR MEDICARE
168305OtherBCBS
000015519Medicare PIN
000082169Medicare PIN
000040056Medicare PIN