Basic Information
| Provider Information | |||||||||
| NPI: | 1578551065 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLASTIC SURGERY CONSULTANTS, P.C. | ||||||||
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| OtherOrganizationName: | PLASTIC SURGERY CONSULTANTS OF ILLINOIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 MEMORIAL DR | ||||||||
| Address2: | MEDICAL OFFICE BUILDING 2 - SUITE 320 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572100 | ||||||||
| FaxNumber: | 6182572169 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 MEMORIAL DR | ||||||||
| Address2: | MEDICAL OFFICE BUILDING 2 - SUITE 320 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182572100 | ||||||||
| FaxNumber: | 6182572169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WANLESS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182572100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.