Provider Demographics
NPI:1720085384
Name:ELMHURST OUTPATIENT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:ELMHURST OUTPATIENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MADONIA
Authorized Official - Last Name:MENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-758-8801
Mailing Address - Street 1:1200 SOUTH YORK RD
Mailing Address - Street 2:STE 1400
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5633
Mailing Address - Country:US
Mailing Address - Phone:630-758-8800
Mailing Address - Fax:630-758-8805
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:STE 1400
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5633
Practice Address - Country:US
Practice Address - Phone:630-758-8800
Practice Address - Fax:630-758-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002330261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL490004570OtherMEDICARE FOR RAILROAD EMPLOYEES
141082Medicare PIN
IL490004570OtherMEDICARE FOR RAILROAD EMPLOYEES