Provider Demographics
NPI:1104051978
Name:HILLSTROM FACIAL PLASTIC SURGERY PA
Entity type:Organization
Organization Name:HILLSTROM FACIAL PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:HILLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-355-3223
Mailing Address - Street 1:BOX 195
Mailing Address - Street 2:8374 MARKET STREET
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-5137
Mailing Address - Country:US
Mailing Address - Phone:941-355-3223
Mailing Address - Fax:941-358-9749
Practice Address - Street 1:5911 N. HONORE AVE.
Practice Address - Street 2:SUITE 120
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243
Practice Address - Country:US
Practice Address - Phone:941-355-3223
Practice Address - Fax:941-358-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54913207Y00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00078356OtherRAILROAD
FLE22494Medicare UPIN
FLP00078356OtherRAILROAD