Provider Demographics
NPI:1790939783
Name:MIDTOWN PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:MIDTOWN PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PULI
Authorized Official - Middle Name:PRAVIN
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-754-1994
Mailing Address - Street 1:925B PEACHTREE ST NE UNIT 375
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3918
Mailing Address - Country:US
Mailing Address - Phone:404-754-1994
Mailing Address - Fax:770-783-8975
Practice Address - Street 1:1418 DRESDEN DR NE STE 120
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-3599
Practice Address - Country:US
Practice Address - Phone:404-754-1994
Practice Address - Fax:770-783-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046220208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1487835260OtherNPI INDIVIDUAL