Provider Demographics
NPI:1952720880
Name:COMMONWEALTH PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:COMMONWEALTH PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:NIMTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-420-3256
Mailing Address - Street 1:715 SHAKER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3674
Mailing Address - Country:US
Mailing Address - Phone:859-277-9435
Mailing Address - Fax:859-277-8852
Practice Address - Street 1:715 SHAKER DR STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3674
Practice Address - Country:US
Practice Address - Phone:859-277-9435
Practice Address - Fax:859-277-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46515208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty