Provider Demographics
NPI:1568620144
Name:HEALTH & RENEWAL PLASTIC SURGERY ASSOCIATES, S.C.
Entity Type:Organization
Organization Name:HEALTH & RENEWAL PLASTIC SURGERY ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREVIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-952-1400
Mailing Address - Street 1:849 W OHIO ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8901
Mailing Address - Country:US
Mailing Address - Phone:630-952-1400
Mailing Address - Fax:630-952-1447
Practice Address - Street 1:3845 MCCOY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4105
Practice Address - Country:US
Practice Address - Phone:630-952-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100551Medicaid
IL036100551Medicaid