Provider Demographics
NPI:1073745634
Name:NORTHEAST FLORIDA PLASTIC SURGERY
Entity type:Organization
Organization Name:NORTHEAST FLORIDA PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-215-5800
Mailing Address - Street 1:421 KINGSLEY AVE
Mailing Address - Street 2:#200
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4897
Mailing Address - Country:US
Mailing Address - Phone:904-215-5800
Mailing Address - Fax:904-215-1211
Practice Address - Street 1:421 KINGSLEY AVE
Practice Address - Street 2:#200
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4897
Practice Address - Country:US
Practice Address - Phone:904-215-5800
Practice Address - Fax:904-215-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF42140Medicare UPIN
FL18187AMedicare PIN