Provider Demographics
NPI:1093882615
Name:UNIVERSITY PLASTIC SURGEONS INC
Entity Type:Organization
Organization Name:UNIVERSITY PLASTIC SURGEONS INC
Other - Org Name:UNIVERSITY PLASTIC SURGERY ASSOCIATES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BEVIVINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-521-9290
Mailing Address - Street 1:120 DUDLEY STREET
Mailing Address - Street 2:SUITE #201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905
Mailing Address - Country:US
Mailing Address - Phone:401-521-9290
Mailing Address - Fax:401-521-9297
Practice Address - Street 1:120 DUDLEY STREET
Practice Address - Street 2:SUITE #201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-521-9290
Practice Address - Fax:401-521-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRIMD05259208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002112Medicaid
RI1300124OtherUNITED HEALTH CARE
RI21126OtherBCBS
RI21126OtherBCBS