Provider Demographics
NPI:1467512756
Name:MIDWEST CENTER FOR PLASTIC SURGERY
Entity Type:Organization
Organization Name:MIDWEST CENTER FOR PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-876-9987
Mailing Address - Street 1:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62524-2077
Mailing Address - Country:US
Mailing Address - Phone:217-876-9987
Mailing Address - Fax:217-876-1792
Practice Address - Street 1:1 MEMORIAL DR STE 216
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6321
Practice Address - Country:US
Practice Address - Phone:217-876-9987
Practice Address - Fax:217-876-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH36194Medicare UPIN
IL639620Medicare ID - Type Unspecified