MEDICARE: BRIDGEPORT SURGICENTER, INC

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		IL

General Provider Information

NPI Number	:	1891816450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT SURGICENTER, INC

Provider Business Mailing Address
First Line	:	436 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3136
Country	:	US
Telephone Number	:	815-254-7872
Fax Number	:	815-254-7873

Provider Business Practice Location Address
First Line	:	436 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3136
Country	:	US
Telephone Number	:	815-254-7872
Fax Number	:	815-254-7873

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTHONY PEREZ
Credential	:	DPM
Telephone Number	:	815-254-7872

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/21/2022

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