Healthcare Provider Details

I. General information

NPI: 1770537227
Provider Name (Legal Business Name): WEST SUBURBAN EYE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 MAIN ST
WALTHAM MA
02451-1623
US

IV. Provider business mailing address

1440 MAIN ST
WALTHAM MA
02451-1623
US

V. Phone/Fax

Practice location:
  • Phone: 781-891-9300
  • Fax: 781-891-9305
Mailing address:
  • Phone: 781-891-9300
  • Fax: 781-891-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW J GILLIES
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 781-891-9300