Provider Demographics
NPI:1295885465
Name:PLASTIC SURGERY CENTER OF THE SOUTH
Entity type:Organization
Organization Name:PLASTIC SURGERY CENTER OF THE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:LEAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-421-1242
Mailing Address - Street 1:120 VANN ST NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7250
Mailing Address - Country:US
Mailing Address - Phone:772-421-1242
Mailing Address - Fax:770-424-6652
Practice Address - Street 1:120 VANN ST NE
Practice Address - Street 2:SUITE 150
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7250
Practice Address - Country:US
Practice Address - Phone:772-421-1242
Practice Address - Fax:770-424-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center