Provider Demographics
NPI:1811185481
Name:PREMIERE CENTER FOR COSMETIC SURGERY
Entity Type:Organization
Organization Name:PREMIERE CENTER FOR COSMETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-305-9100
Mailing Address - Street 1:2419 W KENNEDY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3481
Mailing Address - Country:US
Mailing Address - Phone:813-400-1465
Mailing Address - Fax:813-386-0513
Practice Address - Street 1:3930 PENDER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:703-752-6608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001237Medicare PIN