Provider Demographics
NPI:1760589972
Name:THE PLASTIC SURGERY GROUP PA
Entity Type:Organization
Organization Name:THE PLASTIC SURGERY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-233-1933
Mailing Address - Street 1:37 N FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3426
Mailing Address - Country:US
Mailing Address - Phone:973-233-1933
Mailing Address - Fax:973-233-1934
Practice Address - Street 1:37 NORTH FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-233-1933
Practice Address - Fax:973-233-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ091592Medicare PIN