Provider Demographics
NPI:1104005776
Name:UNIVERSITY PLASTIC SURGEONS, INC.
Entity Type:Organization
Organization Name:UNIVERSITY PLASTIC SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MNGT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-691-4000
Mailing Address - Street 1:1611 S GREEN RD
Mailing Address - Street 2:#238
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:216-691-4000
Mailing Address - Fax:216-691-4004
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:#238
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-691-4000
Practice Address - Fax:216-691-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 059617174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0801412Medicaid
OH0879081Medicaid
OH0801412Medicaid
OHUN9249911Medicare PIN
OHE76474Medicare UPIN