Provider Demographics
NPI:1487846580
Name:TRIPTI BURT PLASTIC SURGERY SC
Entity Type:Organization
Organization Name:TRIPTI BURT PLASTIC SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRIPTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-318-5010
Mailing Address - Street 1:1345 EDWARDS ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1692
Mailing Address - Country:US
Mailing Address - Phone:815-318-5010
Mailing Address - Fax:815-941-6431
Practice Address - Street 1:1345 EDWARDS ST STE 1
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1692
Practice Address - Country:US
Practice Address - Phone:815-318-5010
Practice Address - Fax:815-941-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00168904OtherRAIL ROAD MEDICARE
IL3232017OtherBLUE SHIELD
ILP00168904OtherRAIL ROAD MEDICARE
IL3232017OtherBLUE SHIELD
IL210322Medicare PIN