Provider Demographics
NPI:1649373929
Name:BERKSHIRE PLASTIC SURGEONS PLLC
Entity type:Organization
Organization Name:BERKSHIRE PLASTIC SURGEONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HAIDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-841-3311
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-841-3311
Mailing Address - Fax:931-841-3314
Practice Address - Street 1:105 LEDFORD MILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8261
Practice Address - Country:US
Practice Address - Phone:931-841-3311
Practice Address - Fax:931-841-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD44645208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA68240Medicare UPIN