Provider Demographics
NPI:1942425681
Name:THE PLASTIC SURGERY AND AESTHETIC CENTER OF JACKSONVILLE AND BEACHES
Entity Type:Organization
Organization Name:THE PLASTIC SURGERY AND AESTHETIC CENTER OF JACKSONVILLE AND BEACHES
Other - Org Name:THE AESTHETIC CENTER OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:PALIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-247-0148
Mailing Address - Street 1:700 3RD STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-5082
Mailing Address - Country:US
Mailing Address - Phone:904-247-0148
Mailing Address - Fax:904-247-0574
Practice Address - Street 1:700 3RD STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5082
Practice Address - Country:US
Practice Address - Phone:904-247-0148
Practice Address - Fax:904-247-0574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95604208200000X
FLME101653208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty