Provider Demographics
NPI:1356361794
Name:FACIAL PLASTIC SURGERY OTOLARYNGOLOGY LLC
Entity type:Organization
Organization Name:FACIAL PLASTIC SURGERY OTOLARYNGOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:OVCHINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-646-1234
Mailing Address - Street 1:PO BOX 2625
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8925
Mailing Address - Country:US
Mailing Address - Phone:914-222-0828
Mailing Address - Fax:
Practice Address - Street 1:2560 OCEAN AVE
Practice Address - Street 2:2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4507
Practice Address - Country:US
Practice Address - Phone:718-646-1234
Practice Address - Fax:718-646-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI02333Medicare UPIN
NYWFW961Medicare ID - Type Unspecified
NYI02333Medicare UPIN