MEDICARE: ILLIANA SURGERY & MEDICAL CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center		IN

General Provider Information

NPI Number	:	1770582264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLIANA SURGERY & MEDICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	701 SUPERIOR AVE
Second Line	:	ATTN: MANAGED CARE
City	:	MUNSTER
State	:	IN
Zip	:	46321-4037
Country	:	US
Telephone Number	:	219-641-3051
Fax Number	:	219-641-4186

Provider Business Practice Location Address
First Line	:	2001 US HIGHWAY 41
Second Line	:
City	:	SCHERERVILLE
State	:	IN
Zip	:	46375-2892
Country	:	US
Telephone Number	:	219-865-7986
Fax Number	:	219-865-7992

Authorized Official
Title or Position	:	CEO
Name	:	VIJAY GUPTA
Credential	:	MD
Telephone Number	:	219-922-4200

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	08/22/2020

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