Provider Demographics
NPI:1972572964
Name:CENTRAL ILLINOIS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRUSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-872-8204
Mailing Address - Street 1:304 W HAY ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6328
Mailing Address - Country:US
Mailing Address - Phone:217-876-8201
Mailing Address - Fax:217-876-8202
Practice Address - Street 1:304 W HAY ST
Practice Address - Street 2:SUITE 114
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6328
Practice Address - Country:US
Practice Address - Phone:217-876-8201
Practice Address - Fax:217-876-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002819261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209816Medicare ID - Type UnspecifiedMEDICARE
IL209409Medicare ID - Type UnspecifiedMEDICARE