=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821088667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUBURBAN SURGICAL ASSOCIATES, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2005
-----------------------------------------------------
Last Update Date | 11/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 908 N ELM ST STE 309
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-484-0621
-----------------------------------------------------
Fax | 708-484-0250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 N ELM ST STE 309
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-484-0621
-----------------------------------------------------
Fax | 708-484-0250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY K ZAWACKI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 708-484-0621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036-079983
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------