1265054969 NPI number — FORD PLASTIC & RECONSTRUCTIVE SURGERY PMC

Table of content: (NPI 1265054969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265054969 NPI number — FORD PLASTIC & RECONSTRUCTIVE SURGERY PMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORD PLASTIC & RECONSTRUCTIVE SURGERY PMC
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:
1265054969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3330 CUMBERLAND BLVD SE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-5996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-951-8427
Provider Business Mailing Address Fax Number:
770-951-2157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4864 BLUEBONNET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-9666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-269-2610
Provider Business Practice Location Address Fax Number:
225-269-2630
Provider Enumeration Date:
05/15/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CHIASSON
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
FORD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
225-269-2610

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD.206865 . This is a "LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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