Provider Demographics
NPI:1922141738
Name:25 EAST SAME DAY SURGERY LLC
Entity Type:Organization
Organization Name:25 EAST SAME DAY SURGERY 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 1:25 E WASHINGTON ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1733
Mailing Address - Country:US
Mailing Address - Phone:312-726-3329
Mailing Address - Fax:312-726-3823
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-726-3329
Practice Address - Fax:312-726-3823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7001969261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1514OtherBCBS
IL=========001Medicaid
IL1514OtherBCBS
IL212150Medicare PIN