Provider Demographics
NPI:1164746244
Name:MARIETTA PLASTIC SURGERY
Entity Type:Organization
Organization Name:MARIETTA PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOCKHORST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-425-0118
Mailing Address - Street 1:149 TOWNE LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4859
Mailing Address - Country:US
Mailing Address - Phone:678-494-2380
Mailing Address - Fax:678-494-2379
Practice Address - Street 1:149 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4859
Practice Address - Country:US
Practice Address - Phone:678-494-2380
Practice Address - Fax:678-494-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 626Medicare PIN