Healthcare Provider Details

I. General information

NPI: 1699751289
Provider Name (Legal Business Name): EASTLAND MEDICAL PLAZA SURGICENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-1997
  • Fax: 309-662-9527
Mailing address:
  • Phone: 309-663-1997
  • Fax: 309-662-9527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002413
License Number StateIL

VIII. Authorized Official

Name: MRS. JACKIE ANN FRYE
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 309-663-1997