Provider Demographics
NPI:1104933696
Name:WEST LAKES SURGERY CENTER LLC
Entity type:Organization
Organization Name:WEST LAKES SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERI
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORMANEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-327-1555
Mailing Address - Street 1:2808 S INGRAM MILL RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4042
Mailing Address - Country:US
Mailing Address - Phone:417-889-2040
Mailing Address - Fax:417-889-2041
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8281
Practice Address - Country:US
Practice Address - Phone:515-974-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0610352Medicaid
IA61026OtherFEDERAL EMPLOYEES HEALTH
IAF252394OtherCARPENTERS DISTRICT COUN
IAF252394OtherCIGNA
IA61026OtherWELLMARK BCBS
IAF252394OtherMIDLANDS AETNA
IA61026OtherWELLMARK HEALTH PLANS IA
IAI18499Medicare PIN