Provider Demographics
NPI:1154342350
Name:RENAISSANCE PLASTIC SURGERY PLLC
Entity type:Organization
Organization Name:RENAISSANCE PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:TKACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-444-8200
Mailing Address - Street 1:2601 KENTUCKY AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003
Mailing Address - Country:US
Mailing Address - Phone:270-444-8200
Mailing Address - Fax:
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:STE 401
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3827
Practice Address - Country:US
Practice Address - Phone:270-444-8200
Practice Address - Fax:270-444-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65907685Medicaid
KY65907685Medicaid