Provider Demographics
NPI:1649452343
Name:MACOURLYN CENTER FOR PLASTIC SURGERY PC
Entity type:Organization
Organization Name:MACOURLYN CENTER FOR PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOODBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-895-9100
Mailing Address - Street 1:PO BOX 11922
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-0039
Mailing Address - Country:US
Mailing Address - Phone:615-895-9100
Mailing Address - Fax:615-895-9200
Practice Address - Street 1:1370 GATEWAY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:615-895-9100
Practice Address - Fax:615-895-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG59496Medicare UPIN