Provider Demographics
NPI:1881631604
Name:METRO EAST SURGICAL SPECIALTY SC
Entity type:Organization
Organization Name:METRO EAST SURGICAL SPECIALTY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-654-8100
Mailing Address - Street 1:1212 BROADWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1960
Mailing Address - Country:US
Mailing Address - Phone:618-654-8100
Mailing Address - Fax:
Practice Address - Street 1:1212 BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1960
Practice Address - Country:US
Practice Address - Phone:618-654-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042008099261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center