Provider Demographics
NPI:1174836126
Name:SURGICAL RENEWAL & AESTHETICS
Entity Type:Organization
Organization Name:SURGICAL RENEWAL & AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-535-5554
Mailing Address - Street 1:1900 CYPRESS CREEK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3513
Mailing Address - Country:US
Mailing Address - Phone:512-535-5554
Mailing Address - Fax:512-454-5252
Practice Address - Street 1:1900 CYPRESS CREEK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3513
Practice Address - Country:US
Practice Address - Phone:512-535-5554
Practice Address - Fax:512-454-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1552208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty