Provider Demographics
NPI:1437399250
Name:ADVANCED COSMETIC & PLASTIC SURGERY
Entity Type:Organization
Organization Name:ADVANCED COSMETIC & PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:FEREYDOON
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAHJOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-780-2770
Mailing Address - Street 1:500 OSBORNE RD NE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:763-780-2770
Mailing Address - Fax:763-780-2812
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:SUITE 130
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-780-2770
Practice Address - Fax:763-780-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23415174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94506Medicare UPIN