Provider Demographics
NPI:1639206030
Name:PEDIATRIC PLASTIC SURGERY AND CRANIOFACIAL ASSOCIATES, PC
Entity type:Organization
Organization Name:PEDIATRIC PLASTIC SURGERY AND CRANIOFACIAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-256-1311
Mailing Address - Street 1:975 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1619
Mailing Address - Country:US
Mailing Address - Phone:404-256-1311
Mailing Address - Fax:404-705-2772
Practice Address - Street 1:975 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1619
Practice Address - Country:US
Practice Address - Phone:404-256-1311
Practice Address - Fax:404-705-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty