Provider Demographics
NPI:1790739894
Name:HIGHLAND AMBULATORY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:HIGHLAND AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-654-8100
Mailing Address - Street 1:1212 BROADWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1960
Mailing Address - Country:US
Mailing Address - Phone:618-654-8100
Mailing Address - Fax:618-654-4563
Practice Address - Street 1:1212 BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1960
Practice Address - Country:US
Practice Address - Phone:618-654-8100
Practice Address - Fax:618-654-4563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002868261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215670Medicare PIN