Provider Demographics
NPI:1124168927
Name:SOUTHEASTERN PLASTIC SURGERY ASSOC., PC
Entity type:Organization
Organization Name:SOUTHEASTERN PLASTIC SURGERY ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PERNIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-345-8820
Mailing Address - Street 1:100 TOWNCENTER
Mailing Address - Street 2:SUITE 111
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-1832
Mailing Address - Country:US
Mailing Address - Phone:205-345-8820
Mailing Address - Fax:205-345-8842
Practice Address - Street 1:100 TOWNCENTER
Practice Address - Street 2:SUITE 111
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-1832
Practice Address - Country:US
Practice Address - Phone:205-345-8820
Practice Address - Fax:205-345-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10631174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS441666528BOtherBCBS OF MS
AL528501310Medicaid
MS240000037OtherMEDICARE
AL51014573OtherBCBS OF AL
AL000014573Medicare ID - Type Unspecified
MS240000037OtherMEDICARE