Provider Demographics
NPI:1912178112
Name:KINGSPORT PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:KINGSPORT PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:F
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:CCP-P
Authorized Official - Phone:423-245-8400
Mailing Address - Street 1:2012 BROOKSIDE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4645
Mailing Address - Country:US
Mailing Address - Phone:423-245-8400
Mailing Address - Fax:423-245-9959
Practice Address - Street 1:2012 BROOKSIDE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4645
Practice Address - Country:US
Practice Address - Phone:423-245-8400
Practice Address - Fax:423-245-9959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN253122086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty