1952323099 NPI number — THE RENAISSANCE CENTER FOR PLASTIC SURGERY

Table of content: (NPI 1952323099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952323099 NPI number — THE RENAISSANCE CENTER FOR PLASTIC SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE RENAISSANCE CENTER FOR PLASTIC SURGERY
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:
1952323099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 JOSEPH SIEWICK DR
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-264-0904
Provider Business Mailing Address Fax Number:
703-264-0906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 JOSEPH SIEWICK DR
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22033-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-264-0904
Provider Business Practice Location Address Fax Number:
703-264-0906
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-264-0904

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 214669 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 12420001 . This is a "CARE FIRST BLUE CHOICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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