1609958776 NPI number — SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON SURGERY

Table of content: (NPI 1609958776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609958776 NPI number — SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON 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:
1609958776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2965 COLONNADE DRIVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-3541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-989-6361
Provider Business Mailing Address Fax Number:
540-989-8697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2965 COLONNADE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-3541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-989-6361
Provider Business Practice Location Address Fax Number:
540-989-6361
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BREINER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-989-6361

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101050226 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 0101050226 , 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)

  • Identifier: 323954 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 089951000 . This is a "QUAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 240000224 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 76991 . This is a "SOUTHERN HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06901051 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 348227 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: AETNA . This is a "4420846" identifier . This identifiers is of the category "OTHER".




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