Provider Demographics
NPI:1952464844
Name:EDWARDSVILLE AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EDWARDSVILLE AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR PHYSICIAN REV CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-221-3641
Mailing Address - Street 1:1573 MALLORY LN STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2895
Mailing Address - Country:US
Mailing Address - Phone:152-221-1400
Mailing Address - Fax:
Practice Address - Street 1:12 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
Practice Address - Country:US
Practice Address - Phone:618-656-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002504261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL141024Medicare PIN