Provider Demographics
NPI:1275748873
Name:NORTHWESTERN ASSOC IN AESTHETIC PLASTIC & CRANIOFACIAL SURGERY SC
Entity Type:Organization
Organization Name:NORTHWESTERN ASSOC IN AESTHETIC PLASTIC & CRANIOFACIAL SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:312-335-9155
Mailing Address - Street 1:150 E HURON ST
Mailing Address - Street 2:SUITE 825
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2999
Mailing Address - Country:US
Mailing Address - Phone:312-335-9155
Mailing Address - Fax:
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 825
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-335-9155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0420045492086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042900Medicaid
IL504520Medicare PIN
ILD13114Medicare UPIN