Provider Demographics
NPI:1427244987
Name:ST CHARLES PLASTIC SURGERY, LTD.
Entity type:Organization
Organization Name:ST CHARLES PLASTIC SURGERY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHADERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:630-762-9697
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-762-9697
Mailing Address - Fax:
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-762-9697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096824208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210497Medicare PIN