1437283983 NPI number — BOARD CERTIFIED PLASTIC SURGEON, P.A.

Table of content: (NPI 1437283983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437283983 NPI number — BOARD CERTIFIED PLASTIC SURGEON, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOARD CERTIFIED PLASTIC SURGEON, P.A.
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:
6
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:
1437283983
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2717 S 74TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72903-5100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-452-9080
Provider Business Mailing Address Fax Number:
479-452-7014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 S 74TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-5100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-452-9080
Provider Business Practice Location Address Fax Number:
479-452-7014
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-452-9080

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  C4716 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105795001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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