Provider Demographics
NPI:1497926893
Name:ADVANCED PLASTIC SURGERY OF TERRE HAUTE, LLC
Entity Type:Organization
Organization Name:ADVANCED PLASTIC SURGERY OF TERRE HAUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-650-2907
Mailing Address - Street 1:100 E HALT DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4210
Mailing Address - Country:US
Mailing Address - Phone:812-232-2100
Mailing Address - Fax:812-232-1980
Practice Address - Street 1:100 E HALT DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4210
Practice Address - Country:US
Practice Address - Phone:812-232-2100
Practice Address - Fax:812-232-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN258360Medicare PIN