Provider Demographics
NPI:1063549178
Name:PLASTIC SURGERY CENTER, P.A.
Entity type:Organization
Organization Name:PLASTIC SURGERY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRES- OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-373-3730
Mailing Address - Street 1:1920 CHADWICK DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3471
Mailing Address - Country:US
Mailing Address - Phone:601-373-3730
Mailing Address - Fax:
Practice Address - Street 1:1920 CHADWICK DR
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3471
Practice Address - Country:US
Practice Address - Phone:601-373-3730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS082612086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05959573Medicaid
MS05959573Medicaid