Provider Demographics
NPI:1861491987
Name:THE PLASTIC SURGERY CENTER LAND, LLC
Entity Type:Organization
Organization Name:THE PLASTIC SURGERY CENTER LAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRECO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-355-8000
Mailing Address - Street 1:5361 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6014
Mailing Address - Country:US
Mailing Address - Phone:912-355-8000
Mailing Address - Fax:912-355-8403
Practice Address - Street 1:5361 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6014
Practice Address - Country:US
Practice Address - Phone:912-355-8000
Practice Address - Fax:912-355-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00735061AMedicaid
GA111093ASCAMedicare PIN
GA00735061AMedicaid