Provider Demographics
NPI:1881729879
Name:MIDWEST SURGICAL ASSOCIATES, S.C.
Entity type:Organization
Organization Name:MIDWEST SURGICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-579-9705
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-579-9705
Mailing Address - Fax:708-579-0346
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 180
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-579-9705
Practice Address - Fax:708-579-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-053291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL273425786603013Medicaid
IL31600057OtherBC BS
IL31600057OtherBC BS