Provider Demographics
NPI:1104033794
Name:CENTER FOR COSMETIC MEDICINE, LTD.
Entity type:Organization
Organization Name:CENTER FOR COSMETIC MEDICINE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:F
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-877-9000
Mailing Address - Street 1:2 MEMORIAL DR STE 310
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3983
Mailing Address - Country:US
Mailing Address - Phone:217-877-9000
Mailing Address - Fax:217-877-9615
Practice Address - Street 1:2 MEMORIAL DR STE 310
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3983
Practice Address - Country:US
Practice Address - Phone:217-877-9000
Practice Address - Fax:217-877-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060776Medicaid
IL036060776Medicaid
ILD14445Medicare UPIN