Provider Demographics
NPI:1295897106
Name:WESTMONT SURGERY CENTER LLC
Entity type:Organization
Organization Name:WESTMONT SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-794-8671
Mailing Address - Street 1:530 N CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-1503
Mailing Address - Country:US
Mailing Address - Phone:630-869-4212
Mailing Address - Fax:630-794-8662
Practice Address - Street 1:530 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1503
Practice Address - Country:US
Practice Address - Phone:630-869-4212
Practice Address - Fax:630-794-8662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002587261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490005583OtherRAILROAD MEDICARE
IL490005583OtherRAILROAD MEDICARE