Provider Demographics
NPI:1285980151
Name:PHYSICIANS SURGERY CENTER AT GOOD SAMARITAN, LLC
Entity type:Organization
Organization Name:PHYSICIANS SURGERY CENTER AT GOOD SAMARITAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOON
Authorized Official - Middle Name:
Authorized Official - Last Name:AHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-899-5703
Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:STE 200
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2476
Mailing Address - Country:US
Mailing Address - Phone:618-899-5703
Mailing Address - Fax:618-899-5704
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:STE 200
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2476
Practice Address - Country:US
Practice Address - Phone:618-899-5703
Practice Address - Fax:618-899-5704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7003172261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14C0001157Medicare Oscar/Certification
ILIL8320Medicare PIN