Provider Demographics
NPI:1578551065
Name:PLASTIC SURGERY CONSULTANTS, P.C.
Entity Type:Organization
Organization Name:PLASTIC SURGERY CONSULTANTS, P.C.
Other - Org Name:PLASTIC SURGERY CONSULTANTS OF ILLINOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WANLESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-257-2100
Mailing Address - Street 1:4600 MEMORIAL DR
Mailing Address - Street 2:MEDICAL OFFICE BUILDING 2 - SUITE 320
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5366
Mailing Address - Country:US
Mailing Address - Phone:618-257-2100
Mailing Address - Fax:618-257-2169
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:MEDICAL OFFICE BUILDING 2 - SUITE 320
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-257-2100
Practice Address - Fax:618-257-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
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
IL211502Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER