NPIMap

Organization Active NPI

Advanced Surgical Technology, LLC

Doing business as AST Primary Care Carlyle

  • Rural Health Clinic/Center
  • Carlyle, IL
National Provider Identifier
1831876838
Registry record updated Jun 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ADVANCED SURGICAL TECHNOLOGY, LLC
Doing business as
AST Primary Care Carlyle
Practice address
1297 Franklin St
Carlyle, IL 62231-1718
Phone
(618) 227-7229
Fax
(618) 227-9275
NPI assigned
Jun 30, 2023
Last updated
Jun 30, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 30, 2023

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

Authorized official

Name
Jennia Rensing
Title
Office Manager
Phone
(618) 899-9200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

1297 Franklin St
Carlyle, IL 62231-1718

Mailing address

1297 Franklin St
Carlyle, IL 62231-1718
Phone (618) 227-7229

Other names 1

  • AST Primary Care Carlyle Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230816001125 IL Part A Provider - Rural Health Clinic 3274857685 Practice locations: Carlyle, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1831876838. Details of each certification follow.

Rural health clinic certification: CCN 783861

Legal name
ADVANCED SURGICAL TECHNOLOGY, LLC
Doing business as
AST PRIMARY CARE CARLYLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 15, 2024
Last certification
Feb 15, 2024
Ownership / control type
1B
Organization structure
LLCProprietary
Enrollment address
1297 Franklin St
Carlyle, IL 62231-1718

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D2286946Ast Primary Care Carlyle1297 Franklin, Carlyle, IL 62231Certificate of waiverAug 6, 2027

National Provider Directory

National Provider Directory
Tax ID family
Advanced Surgical Technology LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Abbey R Dempsey Individual W-2 Managing EmployeeCoo Jul 1, 2023
Udaya Kumara Liyanage Individual 5% Or Greater Direct Ownership InterestOwner Jul 1, 2023 100%
Corporate OfficerCeo Jul 1, 2023
Corporate DirectorCeo Jul 1, 2023
W-2 Managing EmployeeCeo Jul 1, 2023

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1688083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1688083200000",
    "number": "1831876838",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1297 FRANKLIN ST",
            "city": "CARLYLE",
            "state": "IL",
            "postal_code": "622311718",
            "telephone_number": "618-227-7229",
            "fax_number": "618-227-9275"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1297 FRANKLIN ST",
            "city": "CARLYLE",
            "state": "IL",
            "postal_code": "622311718",
            "telephone_number": "618-227-7229",
            "fax_number": "618-227-9275"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED SURGICAL TECHNOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-06-30",
        "last_updated": "2023-06-30",
        "certification_date": "2023-06-30",
        "status": "A",
        "authorized_official_last_name": "RENSING",
        "authorized_official_first_name": "JENNIA",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "618-899-9200"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "AST Primary Care Carlyle",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Carlyle, IL

Sources for this page

Verify at the official NPI Registry.