MEDICARE: AESTHETIC AND RECONSTRUCTIVE SURGERY, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	036-072742	IL

General Provider Information

NPI Number	:	1407031057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC AND RECONSTRUCTIVE SURGERY, S.C.

Provider Business Mailing Address
First Line	:	118 SKOKIE BLVD
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-3050
Country	:	US
Telephone Number	:	847-256-9400
Fax Number	:	847-256-9412

Provider Business Practice Location Address
First Line	:	118 SKOKIE BLVD
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-3050
Country	:	US
Telephone Number	:	847-256-9400
Fax Number	:	847-256-9412

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. GERALYN B WALSH
Credential	:
Telephone Number	:	847-256-9400

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	03/03/2009

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