Provider Demographics
NPI:1023429818
Name:MONTICELLO PLASTIC AND RECONSTRUCTIVE SURGERY, PC
Entity type:Organization
Organization Name:MONTICELLO PLASTIC AND RECONSTRUCTIVE SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHOWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-260-5130
Mailing Address - Street 1:PO BOX 5508
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-0508
Mailing Address - Country:US
Mailing Address - Phone:757-340-3489
Mailing Address - Fax:757-340-4278
Practice Address - Street 1:1490 PANTOPS MOUNTAIN PL
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4601
Practice Address - Country:US
Practice Address - Phone:434-260-5130
Practice Address - Fax:434-995-5948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012553902086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1023429818Medicaid
VAD704Medicare PIN