Provider Demographics
NPI:1225151418
Name:WOODBURY PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:WOODBURY PLASTIC SURGERY PA
Other - Org Name:DAVID THAO PLASTIC SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MALAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:THAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-730-4100
Mailing Address - Street 1:604 BIELENBERG DR
Mailing Address - Street 2:STE 250
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1414
Mailing Address - Country:US
Mailing Address - Phone:651-730-4100
Mailing Address - Fax:651-730-4107
Practice Address - Street 1:604 BIELENBERG DR
Practice Address - Street 2:STE 250
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1414
Practice Address - Country:US
Practice Address - Phone:651-730-4100
Practice Address - Fax:651-730-4107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47379261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430093900Medicaid
MN240000306Medicare PIN
MNI28480Medicare UPIN