MEDICARE: PHYSICIANS SURGERY CENTER AT GOOD SAMARITAN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	7003172	IL

General Provider Information

NPI Number	:	1285980151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS SURGERY CENTER AT GOOD SAMARITAN, LLC

Provider Business Mailing Address
First Line	:	2 GOOD SAMARITAN WAY
Second Line	:	STE 200
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2476
Country	:	US
Telephone Number	:	618-899-5703
Fax Number	:	618-899-5704

Provider Business Practice Location Address
First Line	:	2 GOOD SAMARITAN WAY
Second Line	:	STE 200
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2476
Country	:	US
Telephone Number	:	618-899-5703
Fax Number	:	618-899-5704

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL - OWNER
Name	:	JOON AHN
Credential	:	MD
Telephone Number	:	618-899-5703

Provider Enumeration Date	:	07/30/2012
Last Update Date	:	01/08/2025

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