Provider Demographics
NPI:1659569416
Name:PLASTIC SURGERY OF GREATER HARTFORD LLC
Entity Type:Organization
Organization Name:PLASTIC SURGERY OF GREATER HARTFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SCHREIBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-243-1889
Mailing Address - Street 1:1 BARNARD LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2481
Mailing Address - Country:US
Mailing Address - Phone:860-243-1889
Mailing Address - Fax:860-243-5733
Practice Address - Street 1:1 BARNARD LN
Practice Address - Street 2:SUITE 102
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2481
Practice Address - Country:US
Practice Address - Phone:860-243-1889
Practice Address - Fax:860-243-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034529208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF83343Medicare UPIN