Provider Demographics
NPI:1134382716
Name:REGIONAL SURGICENTER LTD
Entity type:Organization
Organization Name:REGIONAL SURGICENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KACHEVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-277-1120
Mailing Address - Street 1:545 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-5560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGIONAL SURGICENTER LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0430674291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL214277Medicare PIN
IL=========002Medicaid