Provider Demographics
NPI:1568690469
Name:NORTHSHORE PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:NORTHSHORE PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-588-4644
Mailing Address - Street 1:3401 E CAUSEWAY APPROACH
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3447
Mailing Address - Country:US
Mailing Address - Phone:985-237-6050
Mailing Address - Fax:
Practice Address - Street 1:3401 E CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3447
Practice Address - Country:US
Practice Address - Phone:985-237-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201940208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty