Provider Demographics
NPI:1518015171
Name:PASTIC AND RECONSTRUCTIVE SURGERY OF ESSEX COUNTY
Entity Type:Organization
Organization Name:PASTIC AND RECONSTRUCTIVE SURGERY OF ESSEX COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPLE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-532-3240
Mailing Address - Street 1:6 ESSEX CENTER DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2910
Mailing Address - Country:US
Mailing Address - Phone:978-532-3240
Mailing Address - Fax:978-532-0526
Practice Address - Street 1:6 ESSEX CENTER DR
Practice Address - Street 2:SUITE 203
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2910
Practice Address - Country:US
Practice Address - Phone:978-532-3240
Practice Address - Fax:978-532-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29094208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M13180Medicare ID - Type Unspecified