1619025350 NPI number — PLASTIC SURGERY SPECIALISTS OF ILLINOIS SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619025350 NPI number — PLASTIC SURGERY SPECIALISTS OF ILLINOIS SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGERY SPECIALISTS OF ILLINOIS SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619025350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20635 ABBEY WOODS CT N
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
FRANKFORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60423-3181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-806-9400
Provider Business Mailing Address Fax Number:
815-806-9550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20635 ABBEY WOODS CT N
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60423-3181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-806-9400
Provider Business Practice Location Address Fax Number:
815-806-9550
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WELKE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
815-806-9400

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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