Provider Demographics
NPI:1598932808
Name:AESTHETIC PLASTIC AND RECONSTRUCTIVE SURGERY, P.C.
Entity Type:Organization
Organization Name:AESTHETIC PLASTIC AND RECONSTRUCTIVE SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-565-4400
Mailing Address - Street 1:776 LONGMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2219
Mailing Address - Country:US
Mailing Address - Phone:413-565-4400
Mailing Address - Fax:413-565-4411
Practice Address - Street 1:776 LONGMEADOW ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-2219
Practice Address - Country:US
Practice Address - Phone:413-565-4400
Practice Address - Fax:413-565-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD87121Medicare UPIN