Provider Demographics
NPI:1154506103
Name:PLASTIC COSMETIC & RECONSTRUCTIVE SURGERY OF MERRIMACK VALLEY INC
Entity Type:Organization
Organization Name:PLASTIC COSMETIC & RECONSTRUCTIVE SURGERY OF MERRIMACK VALLEY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SCULLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-687-1313
Mailing Address - Street 1:451 ANDOVER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5044
Mailing Address - Country:US
Mailing Address - Phone:978-687-1313
Mailing Address - Fax:978-685-8910
Practice Address - Street 1:451 ANDOVER ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5044
Practice Address - Country:US
Practice Address - Phone:978-687-1313
Practice Address - Fax:978-685-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA27779261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD24010Medicare UPIN
MAM12196Medicare UPIN