Provider Demographics
NPI:1407058555
Name:NORTH MECKLENBURG PLASTIC SURGERY
Entity Type:Organization
Organization Name:NORTH MECKLENBURG PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-947-8877
Mailing Address - Street 1:13729 BRAMBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3719
Mailing Address - Country:US
Mailing Address - Phone:704-947-8877
Mailing Address - Fax:
Practice Address - Street 1:403 GILEAD RD
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6813
Practice Address - Country:US
Practice Address - Phone:704-947-8877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201133208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1317VOtherBLUE CROSS
NC5525536OtherAETNA
NC2010838BMedicare PIN
NC1317VOtherBLUE CROSS