1720109325 NPI number — ADVANCED COSMETIC SURGERY AND LASER CENTER, INC.

Table of content: (NPI 1720109325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720109325 NPI number — ADVANCED COSMETIC SURGERY AND LASER CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED COSMETIC SURGERY AND LASER CENTER, INC.
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:
Provider Other Organization Name Type Code:
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:
1720109325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 GERMANTOWN PIKE
Provider Second Line Business Mailing Address:
SUITE E1
Provider Business Mailing Address City Name:
PLYMOUTH MEETING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-275-8710
Provider Business Mailing Address Fax Number:
610-277-2480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 GERMANTOWN PIKE
Provider Second Line Business Practice Location Address:
SUITE E1
Provider Business Practice Location Address City Name:
PLYMOUTH MEETING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-275-8710
Provider Business Practice Location Address Fax Number:
610-277-2480
Provider Enumeration Date:
04/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RABSON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-275-8710

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  M0024621E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0045261000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 052663 . This is a "BSPA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50002 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".