1336267491 NPI number — INNSBROOK PLASTIC SURGERY LLC

Table of content: (NPI 1336267491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336267491 NPI number — INNSBROOK PLASTIC SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNSBROOK PLASTIC SURGERY LLC
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:
INNSBROOK PLASTIC SURGERY
Provider Other Organization Name Type Code:
3
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:
1336267491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4050 INNSLAKE DRIVE
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23060-3327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-346-8700
Provider Business Mailing Address Fax Number:
804-346-1230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4050 INNSLAKE DR
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
GLEN ALLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23060-3327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-346-8700
Provider Business Practice Location Address Fax Number:
804-346-1230
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FERLAND
Authorized Official First Name:
LOUISE
Authorized Official Middle Name:
DIANE
Authorized Official Title or Position:
BUISNESS OWNER
Authorized Official Telephone Number:
804-346-8700

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  0101223586 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 246429 . This is a "BCBS AMB SURGERY CENTER #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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