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General NPI Number Information
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NPI Number | 1467512756
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Entity Type | Organization
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Legal Business Name | MIDWEST CENTER FOR PLASTIC SURGERY
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Dates
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Enumeration Date | 12/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1 MEMORIAL DR STE 216
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City | DECATUR
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State | IL
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Zip | 62526-6321
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Country | US
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Telephone | 217-876-9987
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Fax | 217-876-1792
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Provider Business Mailing Address
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Address Line | PO BOX 2077
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City | DECATUR
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State | IL
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Zip | 62524-2077
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Country | US
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Telephone | 217-876-9987
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Fax | 217-876-1792
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EMMANUELLA JOSEPH
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Credential | MD
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Telephone | 217-876-9987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State | IL
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