Healthcare Provider Details

I. General information

NPI: 1013614734
Provider Name (Legal Business Name): STARSURGICAL 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N HIGHLAND AVE
AURORA IL
60506-1449
US

IV. Provider business mailing address

PO BOX 543
MONTGOMERY IL
60538-0543
US

V. Phone/Fax

Practice location:
  • Phone: 630-859-2222
  • Fax:
Mailing address:
  • Phone: 630-330-1761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSE ESPINO
Title or Position: SURGICAL ASSISTANT
Credential: RCSA
Phone: 630-330-0200