Healthcare Provider Details

I. General information

NPI: 1235109745
Provider Name (Legal Business Name): SURGEONS GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N WESTMORELAND RD SUITE 205
LAKE FOREST IL
60045-1673
US

IV. Provider business mailing address

800 N WESTMORELAND RD SUITE 205
LAKE FOREST IL
60045-1673
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-4310
  • Fax: 847-234-4336
Mailing address:
  • Phone: 847-234-4310
  • Fax: 847-234-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number042-000369
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number042-000369
License Number StateIL

VIII. Authorized Official

Name: MARY DALE HOUSTON
Title or Position: OFFICE MANAGER
Credential: R.N.
Phone: 847-234-4310