Provider Demographics
NPI:1770042111
Name:O'FALLON SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:O'FALLON SURGICAL CENTER, LLC
Other - Org Name:PHYSICIANS SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAKEEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-239-0678
Mailing Address - Street 1:5023 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3453
Mailing Address - Country:US
Mailing Address - Phone:618-239-0678
Mailing Address - Fax:618-235-0471
Practice Address - Street 1:741 INSIGHT AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2193
Practice Address - Country:US
Practice Address - Phone:618-239-0678
Practice Address - Fax:618-235-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2021-07-12
Deactivation Date:2019-05-20
Deactivation Code:
Reactivation Date:2019-05-23
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical