Provider Demographics
NPI:1710084827
Name:CENTER FOR PLASTIC & RECONSTRUCTIVE SURGERY PSC
Entity Type:Organization
Organization Name:CENTER FOR PLASTIC & RECONSTRUCTIVE SURGERY PSC
Other - Org Name:ATALLA PLASTIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FOUAD
Authorized Official - Middle Name:V
Authorized Official - Last Name:ATALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-796-8960
Mailing Address - Street 1:1048 ASHLEY ST STE 303
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-2451
Mailing Address - Country:US
Mailing Address - Phone:270-796-8960
Mailing Address - Fax:270-842-5683
Practice Address - Street 1:1048 ASHLEY ST STE 303
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2451
Practice Address - Country:US
Practice Address - Phone:270-796-8960
Practice Address - Fax:270-842-5683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY337442086S0122X
2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65903460Medicaid
KY6256Medicare PIN