Provider Demographics
NPI:1689097883
Name:PLASTIC SURGERY GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PLASTIC SURGERY GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:NICCOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:949-718-6900
Mailing Address - Street 1:1101 BAYSIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1702
Mailing Address - Country:US
Mailing Address - Phone:949-718-6900
Mailing Address - Fax:
Practice Address - Street 1:1101 BAYSIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1702
Practice Address - Country:US
Practice Address - Phone:949-718-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30397174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26098Medicare UPIN