Provider Demographics
NPI:1992910988
Name:ENTERPRISE SURGICAL ASSISTANCE
Entity type:Organization
Organization Name:ENTERPRISE SURGICAL ASSISTANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:OSTROFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-502-4221
Mailing Address - Street 1:PO BOX 56341
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-0341
Mailing Address - Country:US
Mailing Address - Phone:708-867-4949
Mailing Address - Fax:708-867-4981
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-7696
Practice Address - Fax:773-404-2086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01637103OtherBLUE CROSS BLUE SHIELD OF IL