Basic Information
| Provider Information | |||||||||
| NPI: | 1831137520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN ILLINOIS PLASTIC SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8135 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607142828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479671149 | ||||||||
| FaxNumber: | 8479678594 | ||||||||
| Practice Location | |||||||||
| Address1: | 5714 S IL ROUTE 31 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600144520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153567000 | ||||||||
| FaxNumber: | 8153567513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBERG | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8479671149 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 00732007 | 01 | IL | BLUE SHIELD OF ILLINOIS | OTHER |