Provider Demographics
NPI:1760748800
Name:THE PLASTIC & RECONSTRUCTIVE SURGERY INSTITUTE, LLC
Entity Type:Organization
Organization Name:THE PLASTIC & RECONSTRUCTIVE SURGERY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ZACHARY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-687-9990
Mailing Address - Street 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:SMYTH PROFESSIONAL BLDG., SUITE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2905
Mailing Address - Country:US
Mailing Address - Phone:443-687-9990
Mailing Address - Fax:443-740-9278
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:SMYTH PROFESSIONAL BLDG., SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:443-687-9990
Practice Address - Fax:443-740-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058474208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD107100OtherJOHN HOPKINS - EHP, PRIORITY PARTNERS, US FAMILY
MD1972585206OtherBRAVO
MD1760748800OtherAMERIGROUP
MD1760748800OtherMARYLAND PHYSICIANS CARE
MD1760748800OtherMEDSTAR FAMILY CHOICE
MD1760748800OtherUNITED HEALTHCARE ALL PRODUCTS EXCEPT AMERICHOICE
MDAB87OtherCAREFIRST BLUECROSS BLUESHIELD ALL PRODUCTS
MD1188979OtherCIGNA
MDDS9899OtherRAILROAD MEDICARE
MD1760748800OtherAETNA ALL PRODUCTS
MD241128YHPYMedicare PIN