1679687594 NPI number — PLASTIC & HAND SURGICAL ASSOCIATES

Table of content: (NPI 1679687594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679687594 NPI number — PLASTIC & HAND SURGICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC & HAND SURGICAL ASSOCIATES
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:
WESTERN AVENUE DAY SURGERY CENTER
Provider Other Organization Name Type Code:
5
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:
1679687594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
244 WESTERN AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-2496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-775-3446
Provider Business Mailing Address Fax Number:
207-879-1646

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
244 WESTERN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-2496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-775-3446
Provider Business Practice Location Address Fax Number:
207-879-1646
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
207-775-3446

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 107150000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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