Healthcare Provider Details

I. General information

NPI: 1902849227
Provider Name (Legal Business Name): EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 N ILLINOIS ST
BELLEVILLE IL
62226
US

IV. Provider business mailing address

3990 N ILLINOIS ST LOWER LEVEL
BELLEVILLE IL
62226-1919
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-1130
  • Fax: 618-948-7624
Mailing address:
  • Phone: 618-277-1130
  • Fax: 618-948-7624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7001316
License Number StateIL

VIII. Authorized Official

Name: MICHAEL P JONES
Title or Position: PRESIDENT
Credential: MD
Phone: 618-277-1130