Provider Demographics
NPI:1083798029
Name:THE CLINIC OF PLASTIC SURGERY, P.A.
Entity Type:Organization
Organization Name:THE CLINIC OF PLASTIC SURGERY, P.A.
Other - Org Name:THE CLINIC OF PLASTIC SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-969-9050
Mailing Address - Street 1:1421 NORTH STATE ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202
Mailing Address - Country:US
Mailing Address - Phone:601-969-9056
Mailing Address - Fax:601-354-2443
Practice Address - Street 1:1421 NORTH STATE ST
Practice Address - Street 2:SUITE 504
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-969-9050
Practice Address - Fax:601-354-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5413208200000X, 208200000X
MS19109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS240000013Medicare UPIN
MS01889374Medicare UPIN
MS240000103Medicare UPIN