Provider Demographics
NPI:1033306998
Name:AESTHETIC CENTER OF PLASTIC SURGERY
Entity Type:Organization
Organization Name:AESTHETIC CENTER OF PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-255-3311
Mailing Address - Street 1:115 W CENTURY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1403
Mailing Address - Country:US
Mailing Address - Phone:701-255-3311
Mailing Address - Fax:701-255-2255
Practice Address - Street 1:115 W CENTURY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1403
Practice Address - Country:US
Practice Address - Phone:701-255-3311
Practice Address - Fax:701-255-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDBP4905482174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18831Medicaid
ND18831Medicaid