1619479201 NPI number — CELESTIAL PLASTIC AND RECONSTRUCTIVE SURGERY

Table of content: (NPI 1619479201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619479201 NPI number — CELESTIAL PLASTIC AND RECONSTRUCTIVE SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CELESTIAL PLASTIC AND RECONSTRUCTIVE 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:
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:
1619479201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3645 MARKETPLACE BLVD STE 130-559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST POINT
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30344-5747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-845-0696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 GODBY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30349-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-268-0828
Provider Business Practice Location Address Fax Number:
404-393-1695
Provider Enumeration Date:
02/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CELESTIN
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
Authorized Official Title or Position:
PLASTIC SURGEON, OWNER
Authorized Official Telephone Number:
770-845-0696

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 70539 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DZ9723 . This is a "RAIROAD MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003211917A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972708899 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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