Healthcare Provider Details

I. General information

NPI: 1306074521
Provider Name (Legal Business Name): AESTHETIC INSTITUTE OF CHICAGO, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W RANDOLPH ST
CHICAGO IL
60661-2232
US

IV. Provider business mailing address

601 W RANDOLPH ST
CHICAGO IL
60661-2232
US

V. Phone/Fax

Practice location:
  • Phone: 312-258-9100
  • Fax: 312-258-1219
Mailing address:
  • Phone: 312-258-9100
  • Fax: 312-258-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036096170
License Number StateIL

VIII. Authorized Official

Name: BRIAN MICHAEL BRAITHWAITE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-258-9100