Provider Demographics
NPI:1821068891
Name:SOUTHEASTERN PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:SOUTHEASTERN PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENSON
Authorized Official - Middle Name:EL
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:704-866-4005
Mailing Address - Street 1:649 N NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7424
Mailing Address - Country:US
Mailing Address - Phone:704-866-4005
Mailing Address - Fax:704-866-0450
Practice Address - Street 1:649 N NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7424
Practice Address - Country:US
Practice Address - Phone:704-866-4005
Practice Address - Fax:704-866-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0269XOtherBCBS
NC890269XMedicaid
NC2323181BMedicare ID - Type Unspecified
NC2323181Medicare ID - Type Unspecified
NC2323181CMedicare ID - Type Unspecified