Provider Demographics
NPI:1063783660
Name:ELAN PLASTIC SURGERY PC
Entity type:Organization
Organization Name:ELAN PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-509-4091
Mailing Address - Street 1:15 WORMANS MILL CT STE L-M
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3019
Mailing Address - Country:US
Mailing Address - Phone:301-698-2400
Mailing Address - Fax:301-698-2460
Practice Address - Street 1:15 WORMANS MILL CT STE L-M
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3019
Practice Address - Country:US
Practice Address - Phone:301-698-2400
Practice Address - Fax:301-698-2460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0037204208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDV6710001OtherCAREFIRST BLUECROSS BLUESHIELD