Provider Demographics
NPI:1023039385
Name:NORTHEAST GEORGIA PLASTIC SURGERY ASSOCIATES, PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:NORTHEAST GEORGIA PLASTIC SURGERY ASSOCIATES, PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICHWINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:M D
Authorized Official - Phone:770-534-1856
Mailing Address - Street 1:1296 SIMS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3850
Mailing Address - Country:US
Mailing Address - Phone:770-534-1856
Mailing Address - Fax:770-531-0355
Practice Address - Street 1:1296 SIMS ST
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3850
Practice Address - Country:US
Practice Address - Phone:770-534-1856
Practice Address - Fax:770-531-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069-037261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical