Provider Demographics
NPI:1003062100
Name:PHYSICIAN SURGERY CENTER
Entity type:Organization
Organization Name:PHYSICIAN SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-342-2255
Mailing Address - Street 1:1207 NETWORK CENTRE DR
Mailing Address - Street 2:P.O. BOX 1294
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4632
Mailing Address - Country:US
Mailing Address - Phone:217-342-2255
Mailing Address - Fax:217-342-2619
Practice Address - Street 1:1500 HWY 72 EAST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-0000
Practice Address - Country:US
Practice Address - Phone:573-426-6301
Practice Address - Fax:573-426-6304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
511377OtherHEALTHLINK
514184OtherHEALTHLINK
168305OtherBCBS
P00443325OtherRAILROAD MEDICARE
825845519Medicare PIN
821695519Medicare PIN
514184OtherHEALTHLINK
825575519Medicare PIN