Provider Demographics
NPI:1972614832
Name:PEACHTREE PLASTIC SURGERY
Entity Type:Organization
Organization Name:PEACHTREE PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-841-8450
Mailing Address - Street 1:3286 NORTHSIDE PKWY NW STE 1000
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2294
Mailing Address - Country:US
Mailing Address - Phone:404-841-8450
Mailing Address - Fax:404-841-8453
Practice Address - Street 1:3286 NORTHSIDE PKWY NW STE 1000
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2294
Practice Address - Country:US
Practice Address - Phone:404-841-8450
Practice Address - Fax:404-841-8453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047345174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000947383AMedicaid
GA24BCBSWMedicare ID - Type Unspecified
GAH64187Medicare UPIN