Provider Demographics
NPI:1952611147
Name:PRINCE WILLIAM PLASTIC SURGERY AND SPA SERVICES COMPANY, LLC
Entity Type:Organization
Organization Name:PRINCE WILLIAM PLASTIC SURGERY AND SPA SERVICES COMPANY, LLC
Other - Org Name:MICHAEL P GROSS, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-494-1163
Mailing Address - Street 1:1940 OPITZ BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:703-494-1163
Mailing Address - Fax:703-494-2181
Practice Address - Street 1:1940 OPITZ BOULEVARD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-494-1163
Practice Address - Fax:703-494-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty