=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851407795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN ILLINOIS SURGERY CENTER LIMITED PATRNERSHIP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 06/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 E DIEHL RD
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-505-7733
-----------------------------------------------------
Fax | 630-799-0223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 REMITTANCE DR SUITE 3278
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60675-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-505-7733
-----------------------------------------------------
Fax | 630-799-0223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS ADMINISTRATOR
-----------------------------------------------------
Name | ANTHONY J FATO
-----------------------------------------------------
Credential | MBA, CASC
-----------------------------------------------------
Telephone | 630-505-3383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 7001860
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------