Provider Demographics
NPI:1306074521
Name:AESTHETIC INSTITUTE OF CHICAGO, S.C.
Entity type:Organization
Organization Name:AESTHETIC INSTITUTE OF CHICAGO, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BRAITHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-258-9100
Mailing Address - Street 1:601 W RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2232
Mailing Address - Country:US
Mailing Address - Phone:312-258-9100
Mailing Address - Fax:312-258-1219
Practice Address - Street 1:601 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2232
Practice Address - Country:US
Practice Address - Phone:312-258-9100
Practice Address - Fax:312-258-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360961702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6061101Medicaid