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General NPI Number Information
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NPI Number | 1437231446
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Entity Type | Organization
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Legal Business Name | ILLINI SURGICAL ASSOCIATES, INC
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 08/29/2007
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Provider Practice Location Address
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Address Line | 6809 ARMSTRONG CT
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City | WOODRIDGE
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State | IL
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Zip | 60517-1526
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Country | US
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Telephone | 630-795-1855
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Fax | 630-795-1844
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Provider Business Mailing Address
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Address Line | PO BOX 5306
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City | WOODRIDGE
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State | IL
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Zip | 60517-0306
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Country | US
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Telephone | 630-795-1855
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Fax | 630-795-1844
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. KEITH ALLEN PENROD
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Credential | RSA
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Telephone | 630-795-1855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State | IL
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