MEDICARE: PLASTIC AND RECONSTRUCTIVE SURGERY CENTER SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2082S0105X	Surgery of the Hand (Plastic Surgery) Physician	036087458	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528368016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASTIC AND RECONSTRUCTIVE SURGERY CENTER SC

Provider Business Mailing Address
First Line	:	3443 N KENNICOTT AVE
Second Line	:
City	:	ARLINGTON HTS
State	:	IL
Zip	:	60004-1431
Country	:	US
Telephone Number	:	847-577-6400
Fax Number	:	847-577-3194

Provider Business Practice Location Address
First Line	:	3443 N KENNICOTT AVE
Second Line	:
City	:	ARLINGTON HTS
State	:	IL
Zip	:	60004-1431
Country	:	US
Telephone Number	:	847-577-6400
Fax Number	:	847-577-3194

Authorized Official
Title or Position	:	CEO
Name	:	DR. JOHN A. KOTIS
Credential	:	D.O.
Telephone Number	:	847-577-6400

Provider Enumeration Date	:	10/30/2010
Last Update Date	:	10/30/2010

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