Provider Demographics
NPI:1780684449
Name:ILLIANA SURGERY AND MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:ILLIANA SURGERY AND MEDICAL CENTER, LLC
Other - Org Name:THE ORTHOPEDIC CENTERS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-922-4200
Mailing Address - Street 1:701 SUPERIOR AVE
Mailing Address - Street 2:ATTN: MANAGED CARE
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4037
Mailing Address - Country:US
Mailing Address - Phone:219-641-3051
Mailing Address - Fax:219-641-4186
Practice Address - Street 1:6375 US HIGHWAY 6
Practice Address - Street 2:STE 3
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5111
Practice Address - Country:US
Practice Address - Phone:219-641-3051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150147Medicare ID - Type Unspecified