Provider Demographics
NPI:1023297553
Name:PHYSICIANS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:PHYSICIANS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEFFIELD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-549-5361
Mailing Address - Street 1:2601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1031
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50935OtherBLUE CROSS OF ILLINOIS
878466OtherHEALTH LINK
014101OtherHEALTH ALLIANCE
328614OtherGROUP HEALTH PLANS
328614OtherGROUP HEALTH PLANS
014101OtherHEALTH ALLIANCE
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