Provider Demographics
NPI:1336267491
Name:INNSBROOK PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:INNSBROOK PLASTIC SURGERY LLC
Other - Org Name:INNSBROOK PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUISNESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:FERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-346-8700
Mailing Address - Street 1:4050 INNSLAKE DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3327
Mailing Address - Country:US
Mailing Address - Phone:804-346-8700
Mailing Address - Fax:804-346-1230
Practice Address - Street 1:4050 INNSLAKE DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3327
Practice Address - Country:US
Practice Address - Phone:804-346-8700
Practice Address - Fax:804-346-1230
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNSBROOK PLASTIC SURGERY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101223586261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA246429OtherBCBS AMB SURGERY CENTER #