Provider Demographics
NPI:1356400782
Name:CHAMPAIGN SURGICENTER, LLC
Entity type:Organization
Organization Name:CHAMPAIGN SURGICENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-383-3220
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2955
Mailing Address - Fax:217-326-2996
Practice Address - Street 1:3103 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-902-2300
Practice Address - Fax:217-902-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL007002959261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
025710OtherHEALTH ALLIANCE PROV ID
025710OtherHEALTH ALLIANCE PROV ID
IL210971Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER