Provider Demographics
NPI:1215225636
Name:AESTHETIC SURGERY CENTER LTD
Entity Type:Organization
Organization Name:AESTHETIC SURGERY CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-392-4454
Mailing Address - Street 1:PO BOX 6066
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6066
Mailing Address - Country:US
Mailing Address - Phone:228-392-4454
Mailing Address - Fax:228-392-4533
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 140
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-392-4454
Practice Address - Fax:228-392-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11075208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD80519Medicare UPIN