Provider Demographics
NPI:1568770477
Name:GREENWICH PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:GREENWICH PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-629-1900
Mailing Address - Street 1:2 1/2 DEARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5335
Mailing Address - Country:US
Mailing Address - Phone:203-629-1900
Mailing Address - Fax:212-207-9252
Practice Address - Street 1:2 1/2 DEARFIELD DR
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-5335
Practice Address - Country:US
Practice Address - Phone:203-629-1900
Practice Address - Fax:212-207-9252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0404243208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT240000170OtherPTAN