Provider Demographics
NPI:1366620064
Name:ADVANCED AESTHETICS SURGERY & LASER CENTER, P.C.
Entity type:Organization
Organization Name:ADVANCED AESTHETICS SURGERY & LASER CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:KURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-356-3850
Mailing Address - Street 1:1702 MULLIKIN DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-8305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2111 WEST PARK CT.
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-356-3850
Practice Address - Fax:217-356-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.007842261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL060.007842OtherSTATE OF ILLINOIS
IL444060Medicare UPIN