Provider Demographics
NPI:1013213016
Name:ATLANTA AESTHETIC AND RECONSTRUCTIVE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ATLANTA AESTHETIC AND RECONSTRUCTIVE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:T
Authorized Official - Last Name:WORK
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:404-885-9675
Mailing Address - Street 1:595 PIEDMONT AVE NE STE 320-359
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2478
Mailing Address - Country:US
Mailing Address - Phone:404-885-9675
Mailing Address - Fax:404-875-4017
Practice Address - Street 1:1 BALTIMORE PL NW STE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2117
Practice Address - Country:US
Practice Address - Phone:404-885-9675
Practice Address - Fax:404-875-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-437261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000685352FMedicaid
GA000685352FMedicaid
GAG-1935Medicare UPIN