Provider Demographics
NPI:1821306150
Name:GREENSBORO PLASTIC SURGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:GREENSBORO PLASTIC SURGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-954-2633
Mailing Address - Street 1:2716 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3633
Mailing Address - Country:US
Mailing Address - Phone:336-954-2633
Mailing Address - Fax:336-954-2931
Practice Address - Street 1:2716 HENRY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3633
Practice Address - Country:US
Practice Address - Phone:336-954-2633
Practice Address - Fax:336-954-2931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26162261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8983872Medicaid
NC202689Medicare PIN
NC8983872Medicaid