=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841234150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HINSDALE SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2006
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 SALT CREEK LANE
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-325-5035
-----------------------------------------------------
Fax | 630-325-5134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14201 DALLAS PKWY
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-325-5035
-----------------------------------------------------
Fax | 630-325-5134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER / AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | CHRISTOPHER HARTSHORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-800-2017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 7002314
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------