Provider Demographics
NPI:1265054969
Name:FORD PLASTIC & RECONSTRUCTIVE SURGERY PMC
Entity type:Organization
Organization Name:FORD PLASTIC & RECONSTRUCTIVE SURGERY PMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:CHIASSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-269-2610
Mailing Address - Street 1:3330 CUMBERLAND BLVD SE STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5996
Mailing Address - Country:US
Mailing Address - Phone:770-951-8427
Mailing Address - Fax:770-951-2157
Practice Address - Street 1:4864 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9666
Practice Address - Country:US
Practice Address - Phone:225-269-2610
Practice Address - Fax:225-269-2630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.206865OtherLICENSE