Provider Demographics
NPI:1043427826
Name:PARK RIDGE CENTER FOR PLASTIC SURGERY INC
Entity Type:Organization
Organization Name:PARK RIDGE CENTER FOR PLASTIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SPERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-696-9900
Mailing Address - Street 1:444 N. NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068
Mailing Address - Country:US
Mailing Address - Phone:847-696-9900
Mailing Address - Fax:847-696-9913
Practice Address - Street 1:444 N. NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-696-9900
Practice Address - Fax:847-696-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093576261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093576Medicaid
IL036093576Medicaid
IL580350Medicare ID - Type Unspecified