Center for Cosmetic and Laser Surgery, LLC

Primary specialty

Plastic Surgery PhysicianTaxonomy code 208200000X

License

036084126 Issued in IL

Legal business name

CENTER FOR COSMETIC AND LASER SURGERY, LLC

Practice address

1505 Eastland Dr
Ste 350
Bloomington, IL 61701-3534

Phone

(309) 663-1222

NPI assigned

Feb 6, 2013

Last updated

Feb 6, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jeffrey S Poulter, MDNPI 1174521074

Title

Owner

Phone

(309) 663-1222

Specialties & licenses 1

Addresses

Other identifiers 1

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jeffrey Scott Poulter, M.D.

  • Plastic Surgery Physician
  • Bloomington, IL
  • NPI 1174521074
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1360108800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1360108800000",
    "number": "1215276530",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1505 EASTLAND DR",
            "address_2": "STE 350",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013534",
            "telephone_number": "309-663-1222"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1505 EASTLAND DR",
            "address_2": "STE 350",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617013534",
            "telephone_number": "309-663-1222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTER FOR COSMETIC AND LASER SURGERY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-06",
        "last_updated": "2013-02-06",
        "status": "A",
        "authorized_official_last_name": "POULTER",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "309-663-1222",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": "IL",
            "license": "036084126",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036084126",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Catholic Charities of the Diocese of Peoria
• Catholic Charities of the Diocese of Peoria
• Matthew Christian Caviness, MD
• Center for Comprehensive Services, Inc.
• Center for Comprehensive Services, Inc.
• Center for Healing and Wellness PLLC
• Central Il Medical Equipment, Inc.
• Central Illinois Anesthesiology Associates, LTD
• Central Illinois Center for Wellness, LLC
• Central Illinois Family Eyecare LLC (Bloomington Eye Professionals)

• Plastic Surgery Physician in Bloomington, IL
• Providers in Bloomington, IL by specialty
• Plastic Surgery Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.