Provider Demographics
NPI:1720265770
Name:PLASTIC SURGICENTER INC
Entity Type:Organization
Organization Name:PLASTIC SURGICENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLASTIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:HYTHO
Authorized Official - Middle Name:H
Authorized Official - Last Name:PANTAZELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-369-8777
Mailing Address - Street 1:131 ORNAC
Mailing Address - Street 2:JOHN CUMING BUILDING SUITE 510
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742
Mailing Address - Country:US
Mailing Address - Phone:978-369-8777
Mailing Address - Fax:978-369-5554
Practice Address - Street 1:131 ORNAC
Practice Address - Street 2:JOHN CUMING BUILDING SUITE 510
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742
Practice Address - Country:US
Practice Address - Phone:978-369-8777
Practice Address - Fax:978-369-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29312208200000X, 2082S0099X, 2082S0105X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2010321Medicaid
MA2401005280OtherRR MEDICARE
MAB14059OtherBLUE CROSS