Provider Demographics
NPI:1669976213
Name:THE PLASTIC SURGERY GROUP,PC
Entity type:Organization
Organization Name:THE PLASTIC SURGERY GROUP,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-763-4543
Mailing Address - Street 1:901 RIVERFRONT PARKWAY
Mailing Address - Street 2:STE 100
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-2102
Mailing Address - Country:US
Mailing Address - Phone:423-756-7134
Mailing Address - Fax:
Practice Address - Street 1:1949 GUNBARREL RD STE 303
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3188
Practice Address - Country:US
Practice Address - Phone:423-756-7134
Practice Address - Fax:423-763-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN365022086S0122X, 2086S0105X
TN287962086S0122X, 2086S0105X
TN554332086S0122X, 208200000X
TN267872086S0105X
TN387822086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2006636OtherBLUE CROSS BLUE SHIELD
TNCL7313OtherRAILROAD MEDICARE