Provider Demographics
NPI:1427260207
Name:ILLINOIS VALLEY SURGICAL ASSOCIATES, SC
Entity type:Organization
Organization Name:ILLINOIS VALLEY SURGICAL ASSOCIATES, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:KOKOSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-433-3745
Mailing Address - Street 1:1050 E NORRIS DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1605
Mailing Address - Country:US
Mailing Address - Phone:815-433-3745
Mailing Address - Fax:815-433-6928
Practice Address - Street 1:1050 E NORRIS DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1605
Practice Address - Country:US
Practice Address - Phone:815-433-3745
Practice Address - Fax:815-433-6928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5007522OtherBLUE CROSS BLUE SHIELD
IL205288Medicare ID - Type Unspecified