Provider Demographics
NPI:1619479201
Name:CELESTIAL PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:CELESTIAL PLASTIC AND RECONSTRUCTIVE SURGERY
Other - Org Name:CELESTIAL PLASTIC SURGERY
Other - Org Type:Other Name
Authorized Official - Title/Position:PLASTIC SURGEON, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:CELESTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-845-0696
Mailing Address - Street 1:3645 MARKETPLACE BLVD STE 130-559
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5747
Mailing Address - Country:US
Mailing Address - Phone:770-845-0696
Mailing Address - Fax:
Practice Address - Street 1:2230 GODBY RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5002
Practice Address - Country:US
Practice Address - Phone:404-268-0828
Practice Address - Fax:404-393-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70539208200000X
208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DZ9723OtherRAIROAD MEDICARE PTAN
GA003211917AMedicaid
NJ1972708899Medicaid