Provider Demographics
NPI:1982854568
Name:STATESBORO PLASTIC SURGERY
Entity Type:Organization
Organization Name:STATESBORO PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:BISSECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-681-3330
Mailing Address - Street 1:1402 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-681-3330
Mailing Address - Fax:912-681-3303
Practice Address - Street 1:1402 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-681-3330
Practice Address - Fax:912-681-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061556208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty