Healthcare Provider Details

I. General information

NPI: 1821268772
Provider Name (Legal Business Name): GOLD COAST PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E ERIE ST SUITE 640
CHICAGO IL
60611-2740
US

IV. Provider business mailing address

1 E ERIE ST SUITE 640
CHICAGO IL
60611-2740
US

V. Phone/Fax

Practice location:
  • Phone: 312-988-9300
  • Fax: 312-988-9310
Mailing address:
  • Phone: 312-988-9300
  • Fax: 312-988-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number036104040
License Number StateIL

VIII. Authorized Official

Name: MARY G. FORDE
Title or Position: OFFICE MANAGER
Credential:
Phone: 312-988-9300