Provider Demographics
NPI:1497121024
Name:RAINE CENTER FOR PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:RAINE CENTER FOR PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TALMAGE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-366-2650
Mailing Address - Street 1:1405 W PARK STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2365
Mailing Address - Country:US
Mailing Address - Phone:217-366-2650
Mailing Address - Fax:217-366-2652
Practice Address - Street 1:1405 W PARK ST
Practice Address - Street 2:SUITE 206
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2367
Practice Address - Country:US
Practice Address - Phone:217-366-2650
Practice Address - Fax:217-366-2652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057908208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42825Medicare UPIN