Provider Demographics
NPI:1790827491
Name:SURGICAL ASSOCIATES OF MT VERNON, LTD
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF MT VERNON, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-899-3980
Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-899-3980
Mailing Address - Fax:618-899-4793
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 235
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-899-3980
Practice Address - Fax:618-899-4793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL629601Medicare PIN