Provider Demographics
NPI:1356521595
Name:PLASTIC SURGERY ASSOCIATES OF VALDOSTA
Entity type:Organization
Organization Name:PLASTIC SURGERY ASSOCIATES OF VALDOSTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-242-3002
Mailing Address - Street 1:230 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1858
Mailing Address - Country:US
Mailing Address - Phone:229-242-3002
Mailing Address - Fax:229-242-0644
Practice Address - Street 1:230 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1858
Practice Address - Country:US
Practice Address - Phone:229-242-3002
Practice Address - Fax:229-242-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3238Medicare PIN