Provider Demographics
NPI:1164646071
Name:ATLANTIC PLASTIC SURGERY ASSOCIATES PA
Entity Type:Organization
Organization Name:ATLANTIC PLASTIC SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-431-8819
Mailing Address - Street 1:100 GRIFFIN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7113
Mailing Address - Country:US
Mailing Address - Phone:603-431-8819
Mailing Address - Fax:603-427-2540
Practice Address - Street 1:100 GRIFFIN RD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7113
Practice Address - Country:US
Practice Address - Phone:603-431-8819
Practice Address - Fax:603-427-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02579261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH00000686Medicaid