Healthcare Provider Details

I. General information

NPI: 1538719778
Provider Name (Legal Business Name): CPC SURGICAL SUITE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W COURT ST STE 100
KANKAKEE IL
60901-3673
US

IV. Provider business mailing address

555 W COURT ST STE 100
KANKAKEE IL
60901-3673
US

V. Phone/Fax

Practice location:
  • Phone: 815-929-1520
  • Fax: 815-614-3029
Mailing address:
  • Phone: 815-929-1520
  • Fax: 815-614-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES M KELLY
Title or Position: DOCTOR
Credential: MD
Phone: 815-929-1520