Provider Demographics
NPI:1225228950
Name:MEMPHIS PLASTIC SURGERY GROUP
Entity Type:Organization
Organization Name:MEMPHIS PLASTIC SURGERY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ASGHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLEYNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-761-2400
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 1007B
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5225
Mailing Address - Country:US
Mailing Address - Phone:901-761-2400
Mailing Address - Fax:901-761-9892
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 1007B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-761-2400
Practice Address - Fax:901-761-9892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000008349208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3371390Medicaid
TNB59406Medicare UPIN
TN3371390Medicaid