Provider Demographics
NPI:1669539078
Name:IMAGE PLASTIC SURGERY CENTER, INC
Entity type:Organization
Organization Name:IMAGE PLASTIC SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLADIRAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:AFOLABI-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-745-7925
Mailing Address - Street 1:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4207
Mailing Address - Country:US
Mailing Address - Phone:478-745-7925
Mailing Address - Fax:
Practice Address - Street 1:682 HEMLOCK ST
Practice Address - Street 2:#410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6883
Practice Address - Country:US
Practice Address - Phone:478-745-7925
Practice Address - Fax:478-745-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4733Medicare ID - Type UnspecifiedMEDICARE GROUP #