Provider Demographics
NPI:1104252022
Name:BASHIOUM COSMETIC SURGERY CENTER, LTD.
Entity type:Organization
Organization Name:BASHIOUM COSMETIC SURGERY CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BASHIOUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-449-4900
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2156
Mailing Address - Country:US
Mailing Address - Phone:952-449-4900
Mailing Address - Fax:952-449-9531
Practice Address - Street 1:445 LAKE ST E STE 210
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1671
Practice Address - Country:US
Practice Address - Phone:952-449-4900
Practice Address - Fax:952-449-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty