Provider Demographics
NPI:1194888677
Name:FACIAL PLASTIC & LASER SURGERY
Entity type:Organization
Organization Name:FACIAL PLASTIC & LASER SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:TUDOR
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:309-589-8053
Mailing Address - Street 1:7301 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2017
Mailing Address - Country:US
Mailing Address - Phone:309-589-3233
Mailing Address - Fax:309-689-0312
Practice Address - Street 1:7301 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2017
Practice Address - Country:US
Practice Address - Phone:309-589-3233
Practice Address - Fax:309-689-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center