Provider Demographics
NPI:1992851893
Name:RECONSTRUCTIVE SERVICES MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:RECONSTRUCTIVE SERVICES MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-633-9761
Mailing Address - Street 1:212 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1506
Mailing Address - Country:US
Mailing Address - Phone:714-633-9761
Mailing Address - Fax:714-633-0802
Practice Address - Street 1:212 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1506
Practice Address - Country:US
Practice Address - Phone:714-633-9761
Practice Address - Fax:714-633-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25063207Y00000X, 2086S0122X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Not Answered2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Not Answered2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW9316Medicare ID - Type Unspecified