Provider Demographics
NPI:1659323624
Name:CAROLINA PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:CAROLINA PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-583-1222
Mailing Address - Street 1:100 E WOOD ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3004
Mailing Address - Country:US
Mailing Address - Phone:864-583-1222
Mailing Address - Fax:864-582-5154
Practice Address - Street 1:100 E WOOD ST
Practice Address - Street 2:STE 100
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3004
Practice Address - Country:US
Practice Address - Phone:864-583-1222
Practice Address - Fax:864-582-5154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2042Medicare ID - Type UnspecifiedMEDICARE ID