Provider Demographics
NPI:1033212170
Name:PLASTIC & RECONSTRUCTIVE SURGERY INC
Entity Type:Organization
Organization Name:PLASTIC & RECONSTRUCTIVE SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-728-7950
Mailing Address - Street 1:333 SCHOOL STREET
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-728-7950
Mailing Address - Fax:401-729-7952
Practice Address - Street 1:333 SCHOOL STREET
Practice Address - Street 2:SUITE 305
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-728-7950
Practice Address - Fax:401-729-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1300103OtherUNITED HEALTHCARE
RI001120OtherBLUE CHIP
RI20624OtherBLUE CROSS BLUE SHIELD
0207928001OtherCIGNA