Provider Demographics
NPI:1225437643
Name:QUEEN CITY PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:QUEEN CITY PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENAMUAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-372-5685
Mailing Address - Street 1:3025 SPRINGBANK LN
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3362
Mailing Address - Country:US
Mailing Address - Phone:704-372-5685
Mailing Address - Fax:704-372-5686
Practice Address - Street 1:3025 SPRINGBANK LN
Practice Address - Street 2:SUITE 240
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3362
Practice Address - Country:US
Practice Address - Phone:704-372-5685
Practice Address - Fax:704-372-5686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200901161208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty