Provider Demographics
NPI:1396896684
Name:DREYER AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:DREYER AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP MANAGED HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0450
Mailing Address - Street 1:28602 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1286
Mailing Address - Country:US
Mailing Address - Phone:630-264-8400
Mailing Address - Fax:630-264-8402
Practice Address - Street 1:1221 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1404
Practice Address - Country:US
Practice Address - Phone:630-264-8400
Practice Address - Fax:630-264-8402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7001779261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
590OtherBLUE SHIELD
14C0001061Medicare ID - Type Unspecified
490002368Medicare ID - Type UnspecifiedRAILROAD MEDICARE
590OtherBLUE SHIELD