1619183753 NPI number — STERLING PLASTIC & RECONSTRUCTIVE SURGEONS, INC.

Table of content: (NPI 1619183753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619183753 NPI number — STERLING PLASTIC & RECONSTRUCTIVE SURGEONS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STERLING PLASTIC & RECONSTRUCTIVE SURGEONS, 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:
1619183753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19596
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-918-8330
Provider Business Mailing Address Fax Number:
941-918-8332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8800 S TAMIAMI TRL STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-918-8330
Provider Business Practice Location Address Fax Number:
941-918-8332
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATHIESON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
941-918-8800

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME128227 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2331631 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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