1295822351 NPI number — PLASTIC SURGERY ASSOCIATES OF TIDEWATER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295822351 NPI number — PLASTIC SURGERY ASSOCIATES OF TIDEWATER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGERY ASSOCIATES OF TIDEWATER, 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:
1295822351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MEDICAL PKWY
Provider Second Line Business Mailing Address:
SUITE 316
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-4985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-0047
Provider Business Mailing Address Fax Number:
757-548-3370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 316
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-4985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-547-0047
Provider Business Practice Location Address Fax Number:
757-548-3370
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MERRELL
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-673-6000

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  05286935 , 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)





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