Provider Demographics
NPI:1841477247
Name:SPRINGFIELD NEUROSURGICAL ASSOCAITES, S.C.
Entity type:Organization
Organization Name:SPRINGFIELD NEUROSURGICAL ASSOCAITES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENCEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:217-793-9600
Mailing Address - Street 1:2921 MONTVALE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5359
Mailing Address - Country:US
Mailing Address - Phone:217-793-9600
Mailing Address - Fax:217-793-8975
Practice Address - Street 1:2921 MONTVALE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5359
Practice Address - Country:US
Practice Address - Phone:217-793-9600
Practice Address - Fax:217-793-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078656208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078656Medicaid
IL8420196OtherBCBS OF IL
IL140003749OtherRR MEDICARE
IL8420196OtherBCBS OF IL
ILD83286Medicare UPIN
IL036078656Medicaid