Provider Demographics
NPI:1629393491
Name:SOMA PLASTIC SURGERY AND HAND CLINIC
Entity Type:Organization
Organization Name:SOMA PLASTIC SURGERY AND HAND CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:OSWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-914-0732
Mailing Address - Street 1:2630 COURTHOUSE CIR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9562
Mailing Address - Country:US
Mailing Address - Phone:601-914-0732
Mailing Address - Fax:601-914-5598
Practice Address - Street 1:2630 COURTHOUSE CIR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9562
Practice Address - Country:US
Practice Address - Phone:601-914-0732
Practice Address - Fax:601-914-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18863261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05606851Medicaid
MS1467654376OtherTRICARE
MS9065378OtherAETNA
MS302I248082OtherMEDICARE PTAN