Provider Demographics
NPI:1023105947
Name:PLASTIC RECONSTRUCTIVE & COSMETIC SURGERY PC
Entity type:Organization
Organization Name:PLASTIC RECONSTRUCTIVE & COSMETIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, F,ACS
Authorized Official - Phone:781-489-6228
Mailing Address - Street 1:204 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5420
Mailing Address - Country:US
Mailing Address - Phone:781-489-6218
Mailing Address - Fax:781-489-6751
Practice Address - Street 1:204 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-489-6218
Practice Address - Fax:781-489-6751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA600215OtherTUFTS HEALTH PLAN
MAM12935OtherBCBS GROUP NUMBER
MAM12935Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER