=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285701797
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARTISAN PLASTIC SURGERY, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 MADISON ST SUITE 303
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-6549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-730-9900
-----------------------------------------------------
Fax | 815-730-9940
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 95
-----------------------------------------------------
City | CHANNAHON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60410-0095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-730-9900
-----------------------------------------------------
Fax | 815-730-9940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGEON AND CEO
-----------------------------------------------------
Name | DR. SUSAN M SCHNEIDER
-----------------------------------------------------
Credential | M.D., F.A.C.S.
-----------------------------------------------------
Telephone | 815-730-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 036-089059
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------