Provider Demographics
NPI:1760464481
Name:SURGICAL SPECIALISTS OF CENTRAL ILLINOIS SC
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF CENTRAL ILLINOIS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-428-6300
Mailing Address - Street 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3809
Mailing Address - Country:US
Mailing Address - Phone:217-428-6300
Mailing Address - Fax:217-428-6322
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:STE 200
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3809
Practice Address - Country:US
Practice Address - Phone:217-428-6300
Practice Address - Fax:217-428-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI8411OtherMEDICARE TRAVELERS