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General NPI Number Information
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NPI Number | 1881729879
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Entity Type | Organization
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Legal Business Name | MIDWEST SURGICAL ASSOCIATES, S.C.
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 07/29/2013
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Provider Practice Location Address
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Address Line | 5201 WILLOW SPRINGS RD SUITE 180
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City | LA GRANGE HIGHLANDS
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State | IL
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Zip | 60525-6537
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Country | US
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Telephone | 708-579-9705
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Fax | 708-579-0346
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Provider Business Mailing Address
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Address Line | 5201 WILLOW SPRINGS RD SUITE 180
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City | LA GRANGE HIGHLANDS
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State | IL
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Zip | 60525-6537
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Country | US
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Telephone | 708-579-9705
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Fax | 708-579-0346
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Authorized Official
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Title or Position | PRESIDENT
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Name | COLLEEN ANN HAGEN
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Credential | M.D.
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Telephone | 708-579-9705
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036-053291
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License Number State | IL
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