Provider Demographics
NPI:1174861454
Name:INDIANA PLASTIC SURGERY CENTER, PC
Entity Type:Organization
Organization Name:INDIANA PLASTIC SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:SEVERINAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-489-0099
Mailing Address - Street 1:10020 DUPONT CIRCLE CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1620
Mailing Address - Country:US
Mailing Address - Phone:260-489-0099
Mailing Address - Fax:260-489-0066
Practice Address - Street 1:10020 DUPONT CIRCLE CT
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1620
Practice Address - Country:US
Practice Address - Phone:260-489-0099
Practice Address - Fax:260-489-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043388A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200024970Medicaid
IN200024970Medicaid