Provider Demographics
NPI:1851318521
Name:INGALLS SAME DAY SURGERY CENTER LTD
Entity Type:Organization
Organization Name:INGALLS SAME DAY SURGERY CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENATARE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORBENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-702-0294
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0340
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:6701 159TH ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1758
Practice Address - Country:US
Practice Address - Phone:708-429-0222
Practice Address - Fax:708-429-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7001043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL535OtherBLUECROSS BLUESHIELD
IL=========OtherTAX ID #
IL490000429Medicare PIN