1760748800 NPI number — THE PLASTIC & RECONSTRUCTIVE SURGERY INSTITUTE, LLC

Table of content: (NPI 1760748800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760748800 NPI number — THE PLASTIC & RECONSTRUCTIVE SURGERY INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PLASTIC & RECONSTRUCTIVE SURGERY INSTITUTE, 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:
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:
1760748800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 LOCH RAVEN BLVD
Provider Second Line Business Mailing Address:
SMYTH PROFESSIONAL BLDG., SUITE 200
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21239-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-687-9990
Provider Business Mailing Address Fax Number:
443-740-9278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5601 LOCH RAVEN BLVD
Provider Second Line Business Practice Location Address:
SMYTH PROFESSIONAL BLDG., SUITE 200
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21239-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-687-9990
Provider Business Practice Location Address Fax Number:
443-740-9278
Provider Enumeration Date:
04/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ZACHARY
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
443-687-9990

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  D0058474 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 107100 . This is a "JOHN HOPKINS - EHP, PRIORITY PARTNERS, US FAMILY" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1972585206 . This is a "BRAVO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1760748800 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1760748800 . This is a "MARYLAND PHYSICIANS CARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1760748800 . This is a "MEDSTAR FAMILY CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1760748800 . This is a "UNITED HEALTHCARE ALL PRODUCTS EXCEPT AMERICHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: AB87 . This is a "CAREFIRST BLUECROSS BLUESHIELD ALL PRODUCTS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1188979 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DS9899 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1760748800 . This is a "AETNA ALL PRODUCTS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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