Provider Demographics
NPI:1780743526
Name:PLASTIC SURGERY SPECIALISTS PC
Entity type:Organization
Organization Name:PLASTIC SURGERY SPECIALISTS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:WORLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-773-2110
Mailing Address - Street 1:2959 SISKIYOU BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8131
Mailing Address - Country:US
Mailing Address - Phone:541-773-2110
Mailing Address - Fax:541-734-7368
Practice Address - Street 1:2959 SISKIYOU BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8131
Practice Address - Country:US
Practice Address - Phone:541-773-2110
Practice Address - Fax:541-734-7368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10533208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019802Medicaid
ORR0000BKWBCMedicare PIN
ORC94119Medicare UPIN