Provider Demographics
NPI:1609958776
Name:SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON SURGERY
Entity Type:Organization
Organization Name:SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BREINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-989-6361
Mailing Address - Street 1:2965 COLONNADE DRIVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3541
Mailing Address - Country:US
Mailing Address - Phone:540-989-6361
Mailing Address - Fax:540-989-8697
Practice Address - Street 1:2965 COLONNADE DRIVE
Practice Address - Street 2:SUITE 140
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3541
Practice Address - Country:US
Practice Address - Phone:540-989-6361
Practice Address - Fax:540-989-6361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050226174400000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
323954OtherANTHEM
089951000OtherQUAL CHOICE
240000224OtherUNITED HEALTHCARE
76991OtherSOUTHERN HEALTH
VA06901051Medicaid
348227OtherMAMSI
AETNAOther4420846
AETNAOther4420846
240000224OtherUNITED HEALTHCARE
348227OtherMAMSI