Provider Demographics
NPI:1174655880
Name:MEDICAL COSMETIC CENTER, LLC
Entity Type:Organization
Organization Name:MEDICAL COSMETIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HASTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-476-6161
Mailing Address - Street 1:7145 E VIRGINIA ST
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-9124
Mailing Address - Country:US
Mailing Address - Phone:812-476-6161
Mailing Address - Fax:812-476-6162
Practice Address - Street 1:7145 E VIRGINIA ST
Practice Address - Street 2:SUITE 2000
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9124
Practice Address - Country:US
Practice Address - Phone:812-476-6161
Practice Address - Fax:812-476-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062143A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11564440OtherPROVIDER CAQH NUMBER