Provider Demographics
NPI:1659560407
Name:PLASTIC & RECONSTRUCTIVE SURGERY OF SUMTER, PA
Entity Type:Organization
Organization Name:PLASTIC & RECONSTRUCTIVE SURGERY OF SUMTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CULBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-773-6361
Mailing Address - Street 1:18 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2403
Mailing Address - Country:US
Mailing Address - Phone:803-773-6361
Mailing Address - Fax:803-773-6009
Practice Address - Street 1:18 MILLER RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2403
Practice Address - Country:US
Practice Address - Phone:803-773-6361
Practice Address - Fax:803-773-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty