Healthcare Provider Details

I. General information

NPI: 1336255124
Provider Name (Legal Business Name): ASSOCIATED SURGICAL GROUP, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

IV. Provider business mailing address

7303 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4005
  • Fax: 309-691-6144
Mailing address:
  • Phone: 309-691-4005
  • Fax: 309-691-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number042-000313
License Number StateIL

VIII. Authorized Official

Name: DR. GAVISH N PATEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 309-691-4005