Provider Demographics
NPI:1891816450
Name:BRIDGEPORT SURGICENTER, INC
Entity Type:Organization
Organization Name:BRIDGEPORT SURGICENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-254-7872
Mailing Address - Street 1:436 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3136
Mailing Address - Country:US
Mailing Address - Phone:815-254-7872
Mailing Address - Fax:815-254-7873
Practice Address - Street 1:436 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3136
Practice Address - Country:US
Practice Address - Phone:815-254-7872
Practice Address - Fax:815-254-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID