Provider Demographics
NPI:1760482210
Name:SPECIALISTS IN PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:SPECIALISTS IN PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-785-0505
Mailing Address - Street 1:3633 HARDEN RD
Mailing Address - Street 2:STE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3369
Mailing Address - Country:US
Mailing Address - Phone:919-785-0505
Mailing Address - Fax:919-785-0205
Practice Address - Street 1:3633 HARDEN RD
Practice Address - Street 2:STE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3369
Practice Address - Country:US
Practice Address - Phone:919-785-0505
Practice Address - Fax:919-785-0205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011EMOtherBCBS
NC89011EMMedicaid
NC1760482210Medicare PIN