MEDICARE: PLASTIC SURGERY SPECIALISTS OF ILLINOIS SC

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	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1619025350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASTIC SURGERY SPECIALISTS OF ILLINOIS SC

Provider Business Mailing Address
First Line	:	20635 ABBEY WOODS CT N
Second Line	:	SUITE 202
City	:	FRANKFORT
State	:	IL
Zip	:	60423-3181
Country	:	US
Telephone Number	:	815-806-9400
Fax Number	:	815-806-9550

Provider Business Practice Location Address
First Line	:	20635 ABBEY WOODS CT N
Second Line	:	SUITE 202
City	:	FRANKFORT
State	:	IL
Zip	:	60423-3181
Country	:	US
Telephone Number	:	815-806-9400
Fax Number	:	815-806-9550

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KAREN WELKE
Credential	:
Telephone Number	:	815-806-9400

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/18/2008

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