Provider Demographics
NPI:1114960358
Name:BLACKHAWK PLASTIC SURGERY, A MEDICAL CORP.
Entity type:Organization
Organization Name:BLACKHAWK PLASTIC SURGERY, A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RONAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-736-5757
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:STE 440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-440-3131
Mailing Address - Fax:310-472-9582
Practice Address - Street 1:3600 BLACKHAWK PLAZA CIR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4623
Practice Address - Country:US
Practice Address - Phone:925-736-5757
Practice Address - Fax:925-736-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03987ZMedicare PIN