Provider Demographics
NPI:1407031057
Name:AESTHETIC AND RECONSTRUCTIVE SURGERY, S.C.
Entity Type:Organization
Organization Name:AESTHETIC AND RECONSTRUCTIVE SURGERY, S.C.
Other - Org Name:THE ELYSA FISHER WOMEN'S LIFECENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERALYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-256-9400
Mailing Address - Street 1:118 SKOKIE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3050
Mailing Address - Country:US
Mailing Address - Phone:847-256-9400
Mailing Address - Fax:847-256-9412
Practice Address - Street 1:118 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3050
Practice Address - Country:US
Practice Address - Phone:847-256-9400
Practice Address - Fax:847-256-9412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0727422086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE51726Medicare UPIN