Provider Demographics
NPI:1760777684
Name:BOREALIS PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:BOREALIS PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-421-6599
Mailing Address - Street 1:4977 SKYVIEW CT
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6941
Mailing Address - Country:US
Mailing Address - Phone:231-421-6599
Mailing Address - Fax:231-421-6602
Practice Address - Street 1:4977 SKYVIEW CT
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6941
Practice Address - Country:US
Practice Address - Phone:231-421-6599
Practice Address - Fax:231-421-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010842242086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty