Provider Demographics
NPI:1588621213
Name:SALEM PLASTIC SURGERY INC
Entity Type:Organization
Organization Name:SALEM PLASTIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-768-8483
Mailing Address - Street 1:1345 WESTGATE CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3041
Mailing Address - Country:US
Mailing Address - Phone:336-768-8483
Mailing Address - Fax:336-768-1195
Practice Address - Street 1:1345A WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-768-8483
Practice Address - Fax:336-768-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC75404174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0166UOtherBCBS
NC2325790Medicare PIN