Healthcare Provider Details

I. General information

NPI: 1881631604
Provider Name (Legal Business Name): METRO EAST SURGICAL SPECIALTY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 BROADWAY SUITE B
HIGHLAND IL
62249-1960
US

IV. Provider business mailing address

1212 BROADWAY SUITE B
HIGHLAND IL
62249-1960
US

V. Phone/Fax

Practice location:
  • Phone: 618-654-8100
  • Fax:
Mailing address:
  • Phone: 618-654-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number042008099
License Number StateIL

VIII. Authorized Official

Name: KEITH R THOMAE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-654-8100