Provider Demographics
NPI:1528368016
Name:PLASTIC AND RECONSTRUCTIVE SURGERY CENTER SC
Entity Type:Organization
Organization Name:PLASTIC AND RECONSTRUCTIVE SURGERY CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:847-577-6400
Mailing Address - Street 1:3443 N KENNICOTT AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1431
Mailing Address - Country:US
Mailing Address - Phone:847-577-6400
Mailing Address - Fax:847-577-3194
Practice Address - Street 1:3443 N KENNICOTT AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1431
Practice Address - Country:US
Practice Address - Phone:847-577-6400
Practice Address - Fax:847-577-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-30
Last Update Date:2010-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360874582082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087458Medicaid
IL580130Medicare PIN
IL036087458Medicaid