Provider Demographics
NPI:1316110737
Name:MIDWEST PLASTIC& RECONSTRUCTIVE SURGERY
Entity type:Organization
Organization Name:MIDWEST PLASTIC& RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRDJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTRIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-375-2076
Mailing Address - Street 1:801 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3128
Mailing Address - Country:US
Mailing Address - Phone:773-527-5071
Mailing Address - Fax:773-527-5070
Practice Address - Street 1:5645 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:847-729-4879
Practice Address - Fax:773-527-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107060208600000X, 2086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-107060Medicaid
IL036-107060Medicaid