Provider Demographics
NPI:1013002138
Name:PLASTIC SURGERY CENTER OF NC INC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTER OF NC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:FAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-765-8620
Mailing Address - Street 1:2901 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4009
Mailing Address - Country:US
Mailing Address - Phone:336-765-8620
Mailing Address - Fax:336-768-6236
Practice Address - Street 1:2901 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4009
Practice Address - Country:US
Practice Address - Phone:336-765-8620
Practice Address - Fax:336-768-6236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLASTIC SURGERY CENTER OF NC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000013762202086S0122X
NC2000013554552086S0122X
NC2000013496692086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty