Provider Demographics
NPI:1508903931
Name:PLASTIC SURGERY CLINIC, PLLC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPERITOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:REAGAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:615-771-7718
Mailing Address - Street 1:1909 MALLORY LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2830
Mailing Address - Country:US
Mailing Address - Phone:615-771-7718
Mailing Address - Fax:615-771-6889
Practice Address - Street 1:1909 MALLORY LN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2830
Practice Address - Country:US
Practice Address - Phone:615-771-7718
Practice Address - Fax:615-771-6889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3086254Medicare UPIN