Provider Demographics
NPI:1205018199
Name:FACIAL PLASTIC & COSMETIC SURGERY CENTER LLC
Entity type:Organization
Organization Name:FACIAL PLASTIC & COSMETIC SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-743-4000
Mailing Address - Street 1:10448 OLD OLIVE STREET RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5927
Mailing Address - Country:US
Mailing Address - Phone:314-743-4000
Mailing Address - Fax:314-743-8055
Practice Address - Street 1:10448 OLD OLIVE STREET RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5927
Practice Address - Country:US
Practice Address - Phone:314-743-4000
Practice Address - Fax:314-743-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE56586Medicare UPIN