1720265770 NPI number — PLASTIC SURGICENTER INC

Table of content: (NPI 1720265770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720265770 NPI number — PLASTIC SURGICENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGICENTER 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:
1720265770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 ORNAC
Provider Second Line Business Mailing Address:
JOHN CUMING BUILDING SUITE 510
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-369-8777
Provider Business Mailing Address Fax Number:
978-369-5554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 ORNAC
Provider Second Line Business Practice Location Address:
JOHN CUMING BUILDING SUITE 510
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-369-8777
Provider Business Practice Location Address Fax Number:
978-369-5554
Provider Enumeration Date:
01/22/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PANTAZELOS
Authorized Official First Name:
HYTHO
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PLASTIC SURGEON
Authorized Official Telephone Number:
978-369-8777

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  29312 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2082S0099X , with the licence number: 29312 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2082S0105X , with the licence number: 29312 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 29312 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2010321 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2401005280 . This is a "RR MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B14059 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".