Provider Demographics
NPI:1831280536
Name:EFFINGHAM SURGICAL PARTNERS LLC
Entity Type:Organization
Organization Name:EFFINGHAM SURGICAL PARTNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:904 W TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2178
Mailing Address - Country:US
Mailing Address - Phone:217-342-1234
Mailing Address - Fax:217-342-1230
Practice Address - Street 1:904 W TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2178
Practice Address - Country:US
Practice Address - Phone:217-342-1234
Practice Address - Fax:217-342-1230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002462207L00000X, 261QA1903X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL917760Medicare PIN
IL917770Medicare PIN