Provider Demographics
NPI:1073676755
Name:PARKCREST PLASTIC SURGERY, INC.
Entity Type:Organization
Organization Name:PARKCREST PLASTIC SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-569-9413
Mailing Address - Street 1:845 N. NEW BALLAS COURT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7083
Mailing Address - Country:US
Mailing Address - Phone:314-569-9413
Mailing Address - Fax:314-569-3674
Practice Address - Street 1:845 N. NEW BALLAS COURT
Practice Address - Street 2:SUITE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7083
Practice Address - Country:US
Practice Address - Phone:314-569-9413
Practice Address - Fax:314-569-3674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCB3594OtherRR MEDICARE