Provider Demographics
NPI:1073505129
Name:PLASTIC SURGERY CENTRE INC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTRE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WYSOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-777-5557
Mailing Address - Street 1:85 CONSTITUTION LN
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3694
Mailing Address - Country:US
Mailing Address - Phone:978-777-5557
Mailing Address - Fax:978-777-1615
Practice Address - Street 1:85 CONSTITUTION LN
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3694
Practice Address - Country:US
Practice Address - Phone:978-777-5557
Practice Address - Fax:978-777-1615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9763996Medicaid
MAM14252Medicare ID - Type Unspecified