Provider Demographics
NPI:1710267703
Name:AESTHETIC PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:AESTHETIC PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:HOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-228-7200
Mailing Address - Street 1:416 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6644
Mailing Address - Country:US
Mailing Address - Phone:229-228-7200
Mailing Address - Fax:229-228-5193
Practice Address - Street 1:416 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6644
Practice Address - Country:US
Practice Address - Phone:229-228-7200
Practice Address - Fax:229-228-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18675174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
238212HOOtherBLUE CROSS BLUE SHIELD
GA003112787AMedicaid
238212HOOtherBLUE CROSS BLUE SHIELD