Provider Demographics
NPI:1407914567
Name:RENAISSANCE PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:RENAISSANCE PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:FATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-575-9152
Mailing Address - Street 1:10293 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46290
Mailing Address - Country:US
Mailing Address - Phone:317-575-9152
Mailing Address - Fax:317-575-9281
Practice Address - Street 1:10293 N MERIDIAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDPLS
Practice Address - State:IN
Practice Address - Zip Code:46290
Practice Address - Country:US
Practice Address - Phone:317-575-9152
Practice Address - Fax:317-575-9281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120400AMedicaid
IN100120400AMedicaid
A60367Medicare UPIN