Eastland Medical Plaza Surgicenter, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

7002413 Issued in IL

Legal business name

EASTLAND MEDICAL PLAZA SURGICENTER, LLC

Practice address

1505 Eastland Dr
Bloomington, IL 61701-3534

Phone

(309) 663-1997

Fax

(309) 662-9527

NPI assigned

Dec 16, 2005

Last updated

Jan 6, 2010By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Jackie Ann Frye

Title

Business Office Manager

Phone

(309) 663-1997

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Listed as

Eastland Medical Plaza Surgicenter LLCCCN 14C0001048

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• St Joseph Medical Center

  dba OSFMG - Bloomington

  • Family Medicine Physician
  • Bloomington, IL
  • NPI 1871547414

  Member Of

  NPD member

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

• Bloomington Normal Healthcare, LLC

  • Ambulatory Surgical Clinic/Center
  • Normal, IL
  • NPI 1083613327

  Member Of

  NPD member

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1134691200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1262736000000",
    "number": "1699751289",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1505 EASTLAND DR",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013534",
            "telephone_number": "309-663-1997",
            "fax_number": "309-662-9527"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1505 EASTLAND DR",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013534",
            "telephone_number": "309-663-1997",
            "fax_number": "309-662-9527"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTLAND MEDICAL PLAZA SURGICENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-16",
        "last_updated": "2010-01-06",
        "status": "A",
        "authorized_official_last_name": "FRYE",
        "authorized_official_first_name": "JACKIE",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "BUSINESS OFFICE MANAGER",
        "authorized_official_telephone_number": "309-663-1997",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "IL",
            "license": "7002413",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "7002413",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kiera Michelle Dymit
• East Central Illinois Area Agency on Aging, Inc.
• Eastland Chiropractic LTD
• Eastland Dental Center, LTD.
• Eastland Lifestyle Center
• Eastland Open MRI LLC
• Eastland Psychological Services, LTD.
• Taylor Jolene Eastwood
• Mehrnoosh Ebadi
• Patti Ecker, MA, LCPC

• Ambulatory Surgical Clinic/Center in Bloomington, IL
• Providers in Bloomington, IL by specialty
• Ambulatory Surgical Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.