Healthcare Provider Details

I. General information

NPI: 1578551065
Provider Name (Legal Business Name): PLASTIC SURGERY CONSULTANTS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DR MEDICAL OFFICE BUILDING 2 - SUITE 320
BELLEVILLE IL
62226-5366
US

IV. Provider business mailing address

4600 MEMORIAL DR MEDICAL OFFICE BUILDING 2 - SUITE 320
BELLEVILLE IL
62226-5366
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-2100
  • Fax: 618-257-2169
Mailing address:
  • Phone: 618-257-2100
  • Fax: 618-257-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: ROBERT C. WANLESS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-257-2100