Provider Demographics
NPI:1659324648
Name:AESTHETIC & RECONSTRUCTIVE PLASTIC SURGERY,PLLC
Entity Type:Organization
Organization Name:AESTHETIC & RECONSTRUCTIVE PLASTIC SURGERY,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-785-1220
Mailing Address - Street 1:2304 WESVILL CT
Mailing Address - Street 2:# 360
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-2973
Mailing Address - Country:US
Mailing Address - Phone:919-785-1220
Mailing Address - Fax:919-785-1205
Practice Address - Street 1:2304 WESVILL CT
Practice Address - Street 2:# 360
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2973
Practice Address - Country:US
Practice Address - Phone:919-785-1220
Practice Address - Fax:919-785-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927438Medicaid
NC2328434Medicare ID - Type Unspecified
NC8927438Medicaid