Provider Demographics
NPI:1831137520
Name:NORTHERN ILLINOIS PLASTIC SURGERY
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-967-1149
Mailing Address - Street 1:8135 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-2828
Mailing Address - Country:US
Mailing Address - Phone:847-967-1149
Mailing Address - Fax:847-967-8594
Practice Address - Street 1:5714 S IL ROUTE 31
Practice Address - Street 2:SUITE A
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4520
Practice Address - Country:US
Practice Address - Phone:815-356-7000
Practice Address - Fax:815-356-7513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
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
IL00732007OtherBLUE SHIELD OF ILLINOIS
IL319960Medicare ID - Type Unspecified
ILC75640Medicare UPIN