Provider Demographics
NPI:1972609816
Name:TAKE SHAPE PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:TAKE SHAPE PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:SASSANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-585-3800
Mailing Address - Street 1:4161 NW 5TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2101
Mailing Address - Country:US
Mailing Address - Phone:954-585-3800
Mailing Address - Fax:954-585-6100
Practice Address - Street 1:4161 NW 5TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2101
Practice Address - Country:US
Practice Address - Phone:954-585-3800
Practice Address - Fax:954-585-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6200Medicare ID - Type Unspecified