Provider Demographics
NPI:1649675174
Name:EXECUTIVE PLASTIC SURGERY, PLLC
Entity type:Organization
Organization Name:EXECUTIVE PLASTIC SURGERY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-419-1615
Mailing Address - Street 1:43940 WOODWARD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5025
Mailing Address - Country:US
Mailing Address - Phone:734-419-1615
Mailing Address - Fax:248-934-2185
Practice Address - Street 1:43940 WOODWARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5025
Practice Address - Country:US
Practice Address - Phone:734-419-1615
Practice Address - Fax:248-934-2185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098160208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty