Provider Demographics
NPI:1710916960
Name:LAKE NORMAN PLASTIC SURGERY
Entity Type:Organization
Organization Name:LAKE NORMAN PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-658-9921
Mailing Address - Street 1:PO BOX 15133
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0133
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:LAKE NORMAN MEDICAL & PROFESSIONAL PLAZA, SUITE 106
Practice Address - Street 2:146 MEDICAL PARK RD.
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-658-9921
Practice Address - Fax:704-658-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDO2646OtherRAILROAD MEDICARE
NCP00667059OtherRAILROAD MEDICARE
NC143AROtherBLUE CROSS AND BLUE SHIEL
NC2053619Medicare PIN