Healthcare Provider Details

I. General information

NPI: 1720085384
Provider Name (Legal Business Name): ELMHURST OUTPATIENT SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S YORK RD STE 1400
ELMHURST IL
60126-5633
US

IV. Provider business mailing address

1200 SOUTH YORK RD STE 1400
ELMHURST IL
60126-5633
US

V. Phone/Fax

Practice location:
  • Phone: 630-758-8800
  • Fax: 630-758-8805
Mailing address:
  • Phone: 630-758-8800
  • Fax: 630-758-8805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002330
License Number StateIL

VIII. Authorized Official

Name: TINA MADONIA MENTZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 630-758-8801