Provider Demographics
NPI:1821268772
Name:GOLD COAST PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:GOLD COAST PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:FORDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-988-9300
Mailing Address - Street 1:1 E ERIE ST
Mailing Address - Street 2:SUITE 640
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:312-988-9300
Mailing Address - Fax:312-988-9310
Practice Address - Street 1:1 E ERIE ST
Practice Address - Street 2:SUITE 640
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:312-988-9300
Practice Address - Fax:312-988-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104040207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1548342355OtherNPI
H92062OtherUPIN
H92062OtherUPIN