Provider Demographics
NPI:1821088667
Name:SUBURBAN SURGICAL ASSOCIATES, LTD
Entity Type:Organization
Organization Name:SUBURBAN SURGICAL ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZAWACKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-484-0621
Mailing Address - Street 1:3245 SO GROVE AVE.,STE #202
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3636
Mailing Address - Country:US
Mailing Address - Phone:708-484-0621
Mailing Address - Fax:708-484-0250
Practice Address - Street 1:908 N ELM ST STE 202
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3637
Practice Address - Country:US
Practice Address - Phone:708-484-0621
Practice Address - Fax:708-484-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X
IL036-079983208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01619787OtherBCBSIL GROUP NUMBER
ILPUL3GQNWVE5NMedicaid
IL517410Medicare UPIN