MEDICARE: EASTLAND MEDICAL PLAZA SURGICENTER, 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	7002413	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7002413	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1699751289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTLAND MEDICAL PLAZA SURGICENTER, LLC

Provider Business Mailing Address
First Line	:	1505 EASTLAND DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-3534
Country	:	US
Telephone Number	:	309-663-1997
Fax Number	:	309-662-9527

Provider Business Practice Location Address
First Line	:	1505 EASTLAND DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-3534
Country	:	US
Telephone Number	:	309-663-1997
Fax Number	:	309-662-9527

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	MRS. JACKIE ANN FRYE
Credential	:
Telephone Number	:	309-663-1997

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	01/06/2010

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