Provider Demographics
NPI:1114065935
Name:PRIMA CENTER FOR PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:PRIMA CENTER FOR PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:NAKANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-495-1477
Mailing Address - Street 1:3096 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-7918
Mailing Address - Country:US
Mailing Address - Phone:770-495-1477
Mailing Address - Fax:770-495-1488
Practice Address - Street 1:3096 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-7918
Practice Address - Country:US
Practice Address - Phone:770-495-1477
Practice Address - Fax:770-495-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55001192AMedicaid
GA55001192AMedicaid