Provider Demographics
NPI:1245602069
Name:FLEMING ISLAND PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:FLEMING ISLAND PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-348-0727
Mailing Address - Street 1:916 ALAMEDA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6903
Mailing Address - Country:US
Mailing Address - Phone:904-348-0727
Mailing Address - Fax:904-621-9272
Practice Address - Street 1:1679 EAGLE HARBOR PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4815
Practice Address - Country:US
Practice Address - Phone:904-348-0727
Practice Address - Fax:904-621-9272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-21
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1077492086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty