Provider Demographics
NPI:1720398761
Name:PENINSULA COSMETIC & RECONSTRUCTIVE SURGERY INC
Entity Type:Organization
Organization Name:PENINSULA COSMETIC & RECONSTRUCTIVE SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KANTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-827-8486
Mailing Address - Street 1:4000 COLISEUM DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5906
Mailing Address - Country:US
Mailing Address - Phone:757-827-8486
Mailing Address - Fax:757-827-8718
Practice Address - Street 1:4000 COLISEUM DR
Practice Address - Street 2:SUITE 110
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5906
Practice Address - Country:US
Practice Address - Phone:757-827-8486
Practice Address - Fax:757-827-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041391208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6901409Medicaid
VA6901409Medicaid