Provider Demographics
NPI:1780838763
Name:SOVEREIGN PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:SOVEREIGN PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHULMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-366-5476
Mailing Address - Street 1:1950 ARLINGTON ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3508
Mailing Address - Country:US
Mailing Address - Phone:941-366-5476
Mailing Address - Fax:941-866-7388
Practice Address - Street 1:1950 ARLINGTON ST
Practice Address - Street 2:SUITE 112
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3508
Practice Address - Country:US
Practice Address - Phone:941-366-5476
Practice Address - Fax:941-866-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103128208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBI1647OtherMEDICARE PTAN
FLME103128OtherFLORIDA MEDICAL LICENSE
FLDO9595OtherMEDICARE RAILROAD PTAN