Provider Demographics
NPI:1588072037
Name:CALISOMA COSMETIC SURGERY INSTITUTE LTD
Entity type:Organization
Organization Name:CALISOMA COSMETIC SURGERY INSTITUTE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:ROSANNE
Authorized Official - Last Name:TARAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-659-8005
Mailing Address - Street 1:2760 WYNFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3352
Mailing Address - Country:US
Mailing Address - Phone:312-659-8005
Mailing Address - Fax:815-462-4955
Practice Address - Street 1:1460 MARKET ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4643
Practice Address - Country:US
Practice Address - Phone:312-659-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129138208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201083390AMedicaid