1205867702 NPI number — WAUGH CHAPEL PLASTIC SURGERY SPECIALISTS

Table of content: (NPI 1205867702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205867702 NPI number — WAUGH CHAPEL PLASTIC SURGERY SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAUGH CHAPEL PLASTIC SURGERY SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PLASTIC SURGERY SPECIALISTS, PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205867702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 BRANDERMILL BLVD.
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
GAMBRILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-841-5355
Provider Business Mailing Address Fax Number:
410-841-6821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2448 HOLLY AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-841-5355
Provider Business Practice Location Address Fax Number:
410-841-6821
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOWE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
H
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
410-841-5355

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21C001434 . This is a "MEDICARE SUPPLIER ID NUMB" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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