PEORIA AMBULATORY SURGERY CENTER
NPI 1053362343
Clinic/Center - Ambulatory Surgical in Peoria, IL

NPI Status: Active since May 12, 2006

Contact Information

4909 N GLEN PARK PLACE RD
PEORIA, IL
ZIP 61614
Phone: (309) 690-6012

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  • Organization
  • Clinic/Center
  • Ambulatory Surgical
  • CLIA Number: 14D0648270
  • CLIA Cert. Type: Physician Office
  • CLIA Exp. Date: 08-16-2026

About PEORIA AMBULATORY SURGERY CENTER

This page provides the complete NPI Profile along with additional information for Peoria Ambulatory Surgery Center, a provider established in Peoria, Illinois operating as a Clinic/center, focusing in ambulatory surgical . The healthcare provider is registered in the NPI registry with number 1053362343 assigned on May 2006. The practitioner's primary taxonomy code is 261QA1903X with license number 7001530 (IL). The provider is registered as an organization and their NPI record was last updated 18 years ago. The provider's is doing business as Peoria Ambulatory Surgery Center. The authorized official of this NPI record is Tina M Peugh Mba (Executive Director, Soderstrom Derm)

NPI
1053362343
Provider Legal Name
SODERSTROM DERMATOLOGY CENTER S C
Other Organization Name
PEORIA AMBULATORY SURGERY CENTER
Other Name Type
Doing Business As (3)
Entity Type
Organization
Location Address
4909 N GLEN PARK PLACE RD PEORIA, IL 61614
Location Phone
(309) 690-6012
Mailing Address
4909 N GLEN PARK PLACE RD PEORIA, IL 61614
Mailing Phone
(309) 690-6012
Is Sole Proprietor?
No
Is Organization Subpart?
Yes
Enumeration Date
05-12-2006
Last Update Date
06-25-2008
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Specialty - Primary Taxonomy

The NPI enumerator requires providers to submit at least one taxonomy code. A taxonomy code is a unique 10-character code that describes the healthcare provider type, classification, and the area of specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.

Classification

Clinic/Center Ambulatory Surgical

Taxonomy Code
261QA1903X
Type
Ambulatory Health Care Facilities
License No.
7001530
License State
IL

Insurance Plans Accepted

According to publicly available information the provider might be accepting the following health plans from these health insurance companies:

Specific plan information not avaialable, please contact the provider to verify if your insurance plan is accepted.

Specific plan information not avaialable, please contact the provider to verify if your insurance plan is accepted.

*Please verify directly with this provider to make sure your insurance plan is currently accepted.

Authorized Official

The authorized official is the designated individual with the legal authority to make changes to the provider’s official NPI record. For organizations, the authorized official must be a general partner, chairman of the board, CEO, CFO or a direct owner holding at least a 5 percent stake in the medical organization.

Authorized Official Name

TINA M PEUGH MBA

Authorized Official Title
EXECUTIVE DIRECTOR, SODERSTROM DERM
Authorized Official Phone
(309) 674-7546

Additional Identifiers

The NPI Enumerator encourages providers to submit additional identifiers with their NPI application although the submission of this information is optional. The additional identifier(s) section includes other numbers or codes currently or formerly used as an identifier for the provider by other public healthcare entities. The identifiers may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.

Identifier Type / Code Identifier State Identifier Issuer
=========001MEDICAID (05)IL 
141058MEDICARE PIN (08)IL 

Areas of Expertise

The following services and procedures, recently provided to Medicare patients, illustrate the range of care this provider offers. This list reflects the variety of services available to all patients visiting the practice and is based on 2022 Medicare dataset. In general, the more frequently a provider treats specific conditions or performs particular procedures, the more experienced they become in addressing similar patient needs. The provider has delivered many of the services listed below to Medicare patients. Please note that this list does not include services provided to patients who are not covered by Medicare.

Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm

This procedure involves the intricate repair of a wound that is 1.1 to 2.5 cm long on your eyelids, nose, ears, or lip. The goal is to mend the wound carefully to preserve function and minimize scarring. The process may involve stitching and other techniques.

This service was performed 22 times for 22 patients

Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm

This procedure involves repairing a wound on your eyelids, nose, ears, or lip that is between 2.6 and 7.5 cm long. It's considered complicated due to the location and size. The doctor will clean, treat, and stitch the wound to promote healing.

This service was performed 67 times for 65 patients

Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm

This procedure involves the complex repair of a wound in areas like the forehead, cheeks, chin, mouth, neck, underarms, hands, or feet. The wound size is between 1.1-2.5 cm. This repair may involve multiple layers of sutures and could require reconstruction of the skin.

This service was performed 19 times for 18 patients

Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm

This procedure involves the complex repair of a wound in areas like the forehead, cheeks, chin, mouth, neck, underarms, hands, or feet. The wound size ranges from 2.6-7.5 cm. The process includes cleaning, removing damaged tissue, and stitching the wound for proper healing.

This service was performed 190 times for 186 patients

Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm

This is a procedure to repair a complex wound on your scalp, arm, or leg that is 2.6-7.5 cm long. It involves cleaning, removing damaged tissue, and stitching the wound to promote healing. It's performed under local or general anesthesia.

This service was performed 249 times for 232 patients

Complicated repair of wound of trunk, 2.6-7.5 cm

This service involves the intricate repair of a wound on your body's main structure, between your neck and limbs. The wound measures 2.6-7.5 cm. The procedure includes deep-layer stitching and may involve repairing damaged tissue.

This service was performed 129 times for 116 patients

Full thickness skin graft to nose, ears, eyelids, or lips, 20.0 sq cm or less

A full thickness skin graft is a procedure where a layer of skin is taken from one area of the body and transplanted to another. If it's done on the nose, ears, eyelids, or lips, it helps restore these areas when damaged. The size of the graft is 20.0 sq cm or less.

This service was performed 12 times for 12 patients

Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm

This procedure involves repairing a wound on the face, ears, eyelids, nose, lips, or mouth that measures between 2.6-5.0 cm. The process includes cleaning, suturing if necessary, and dressing the wound to promote healing and prevent infection.

This service was performed 50 times for 48 patients

Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm

This procedure involves the repair of a medium-sized wound (5.1-7.5 cm) on the face, ears, eyelids, nose, lips, or mouth. It's more complex than a simple stitch-up, often requiring layered stitches to ensure proper healing and minimize scarring.

This service was performed 18 times for 17 patients

Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm

This is a procedure to mend a moderate wound between 2.6-7.5 cm on your neck, hands, or feet. It involves cleaning the wound, removing any damaged tissue, and stitching it back together to promote healing and minimize scarring.

This service was performed 26 times for 26 patients

Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm

This procedure involves the repair of a wound between 2.6-7.5 cm located on the scalp, underarms, trunk, arms, or legs. The process includes cleaning, debridement (removal of damaged tissue), and suturing (stitching) of the wound to promote healing.

This service was performed 45 times for 43 patients

Removal and microscopic exam of growth of head, neck, hands, feet, or genitals, 1-5 tissue blocks

This procedure involves the careful removal of a growth from the head, neck, hands, or feet. The removed tissue, divided into 1-5 blocks, is then examined under a microscope to study its characteristics and determine the nature of the growth.

This service was performed 522 times for 452 patients

Removal and microscopic exam of growth of trunk, arms, or legs, 1-5 tissue blocks

This procedure involves the removal of a growth from your trunk, arms, or legs. The removed tissue, divided into 1-5 blocks, is then examined under a microscope to identify any abnormalities. This helps in diagnosing and planning further treatment.

This service was performed 41 times for 38 patients

Removal of cancer skin growth of body, arms, or legs, 1.1-2.0 cm

This procedure involves the surgical removal of a cancerous skin growth on the body, arms, or legs. The growth is between 1.1 and 2.0 cm in size. The goal is to eliminate cancer cells and prevent them from spreading to other parts of the body.

This service was performed 85 times for 75 patients

Removal of cancer skin growth of body, arms, or legs, 2.1-3.0 cm

This procedure involves the removal of a cancerous skin growth, between 2.1 and 3.0 cm, from the body, arms, or legs. The area is numbed, then the growth is carefully cut out. The goal is to eliminate all cancer cells while minimizing scarring.

This service was performed 100 times for 97 patients

Removal of cancer skin growth of body, arms, or legs, 3.1-4.0 cm

This procedure involves removing a cancerous skin growth measuring 3.1-4.0 cm on the body, arms, or legs. The area is numbed, then the growth is carefully cut out. The wound is stitched for healing. Regular follow-ups ensure complete removal and recovery.

This service was performed 55 times for 54 patients

Removal of cancer skin growth of body, arms, or legs, more than 4.0 cm

This procedure involves surgically removing a cancerous skin growth larger than 4.0 cm on your body, arms, or legs. It's a crucial step in preventing the spread of cancer. Local anesthesia is typically used, and recovery time varies. It's a common and safe procedure.

This service was performed 45 times for 41 patients

Removal of cancer skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm

This procedure involves the surgical removal of a cancerous skin growth on the face, ears, eyelids, nose, lips, or mouth. The growth is between 1.1-2.0 cm in size. This is done to prevent the cancer from spreading and to restore health.

This service was performed 17 times for 16 patients

Removal of cancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm

This procedure involves the careful removal of a cancerous skin growth measuring between 1.1 to 2.0 cm, located on the scalp, neck, hands, or feet. The goal is to eliminate the cancer and prevent its spread. This is done under local anesthesia to minimize discomfort.

This service was performed 18 times for 18 patients

Removal of noncancer skin growth of body, arms, or legs, 1.1-2.0 cm

This procedure involves the removal of a noncancerous skin growth on the body, arms, or legs that is between 1.1 and 2.0 cm in size. It's a safe and routine procedure performed by a medical professional to improve your skin health and appearance.

This service was performed 51 times for 47 patients

Removal of noncancer skin growth of body, arms, or legs, 2.1-3.0 cm

This is a procedure where a noncancerous skin growth, sized 2.1-3.0 cm, on the body, arms, or legs is removed. It's typically done under local anesthesia. The process involves cutting out the growth and stitching the skin back together. The aim is to eliminate discomfort and prevent potential health issues.

This service was performed 20 times for 19 patients

Removal of noncancer skin growth of face, ears, eyelids, nose, lips, or mouth, 1.1-2.0 cm

This procedure involves the removal of a noncancerous skin growth on your face, ears, eyelids, nose, lips, or mouth that measures between 1.1-2.0 cm. It's a safe process to enhance your comfort and appearance.

This service was performed 12 times for 12 patients

Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm

This procedure involves the removal of a noncancerous skin growth in areas such as the scalp, neck, hands, or feet. The growth being removed is between 1.1 to 2.0 cm in size. The process is safe, typically involves local anesthesia, and is performed by a healthcare professional.

This service was performed 17 times for 16 patients

Repair of wound of eyelids, nose, ears, or lips by transferring skin, 10.0 sq cm or less

This procedure involves repairing a wound on the eyelids, nose, ears, or lips by moving a small piece of skin (10.0 sq cm or less) from one area to another. The goal is to heal the wound and restore the function and appearance of the affected area.

This service was performed 65 times for 65 patients

Repair of wound of eyelids, nose, ears, or lips by transferring skin, 10.1-30.0 sq cm

This procedure involves repairing a wound on the eyelids, nose, ears, or lips by transferring skin from another part of the body. The size of the skin transferred will be between 10.1 to 30.0 square centimeters. It is performed to restore function and appearance.

This service was performed 15 times for 15 patients

Repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet by transferring skin, 10.0 sq cm or less

This procedure involves repairing a wound on various body parts by transferring skin from another area. The transferred skin, up to 10.0 sq cm, helps to cover the wound, promoting healing and reducing scarring. It's a common method for treating larger or deeper wounds.

This service was performed 13 times for 13 patients

Repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet by transferring skin, 10.1-30.0 sq cm

This procedure involves repairing a wound on specified body areas by transferring skin from another part of the body. The transferred skin, measuring between 10.1 to 30.0 square cm, aids in healing the wound and restoring the skin's normal function.

This service was performed 11 times for 11 patients

CLIA Information

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 applies to facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CLIA Program sets standards for clinical laboratory testing and issues certificates. The NPI / CLIA crosswalk information for this NPI number is:

CLIA Number
14D0648270
Facility Type
Physician Office
Certificate Effective Date
August 17, 2024
Certificate Expiration Date
August 16, 2026
Laboratory Director
JOSHUA KENTOSH
Certificate Type
Certificate of Compliance
Certificate Type Description
This CLIA certificate is issued to Peoria Ambulatory Surgery Center after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements. This type of certificate is issued to laboratories that perform nonwaived (moderate and/or high complexity) testing.

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NPI NPI Number Validation

How NPI Validation Works

The NPI validation process uses the ISO-standard Luhn algorithm, a mathematical "handshake", to ensure that a provider's 10-digit ID is authentic and free of common typing errors.

To verify the NPI 1053362343, we treat the final digit (3) as the Check Digit—the target answer we need to reach. The process begins by taking the first nine digits and adding a constant value of 24, which accounts for the "80840" prefix required for all U.S. health identifiers. We then double every other digit starting from the right and sum the individual digits of those results together. For this specific NPI, that total comes to 57. The final step is to find the difference between that total and the next multiple of ten (60 - 57 = 3).

Digit-by-digit view

Use the first nine digits for the calculation. Starting from the right, double every other digit. The last digit is the check digit and is not part of the calculation.

Pos 1
1
Doubled → 2
Pos 2
0
Unchanged
Pos 3
5
Doubled → 10 → 1 + 0
Pos 4
3
Unchanged
Pos 5
3
Doubled → 6
Pos 6
6
Unchanged
Pos 7
2
Doubled → 4
Pos 8
3
Unchanged
Pos 9
4
Doubled → 8
Check
3
Target digit
Regular digit Doubled digit Check digit

Step 1: Double every other digit from the right

Starting with the rightmost digit of the first nine digits, double every other value. If doubling creates a two-digit number, add those digits together.

1 → 2 5 → 10 → 1 3 → 6 2 → 4 4 → 8

Step 2: Add all digits plus the NPI constant

Add the transformed values, the unchanged digits, and the constant 24.

2 + 0 + 1 + 0 + 3 + 6 + 6 + 4 + 3 + 8 + 24 = 57

Step 3: Find the amount needed to reach the next multiple of 10

The next multiple of ten after 57 is 60. The difference is the calculated check digit.

60 - 57 = 3
This NPI is valid
The calculated check digit is 3, which matches the last digit of 1053362343.

Other Providers at the Same Location


The following 16 providers are registered at the same or a nearby location.

Plastic Surgery
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Physician Assistant (Medical)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Dermatology
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Physician Assistant
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Dermatology
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Physician Assistant
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Physician Assistant
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Surgery (Plastic and Reconstructive Surgery)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Physician Assistant (Medical)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Nurse Practitioner (Acute Care)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Dermatology (Dermatopathology)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Plastic Surgery
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Nurse Practitioner (Family)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Dermatology (Dermatopathology)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Dermatology
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614
Nurse Practitioner (Family)
4909 N GLEN PARK PLACE RD
PEORIA, IL 61614

Frequently Asked Questions

The NPI number assigned to this healthcare provider is 1053362343, enumerated as an "organization" on May 12, 2006.

The provider is located at 4909 N GLEN PARK PLACE RD PEORIA, IL 61614 and the phone number is (309) 690-6012.

Clinic/Center with taxonomy code 261QA1903X and a focus in Ambulatory Surgical.

The provider might be accepting Accepts: Medicare and Medicaid. Please consult your insurance carrier or call the provider to verify.