Provider Demographics
NPI:1194979039
Name:PLASTIC SURGERY SPECIALISTS, PLLC
Entity type:Organization
Organization Name:PLASTIC SURGERY SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-826-0374
Mailing Address - Street 1:2060 E. PARIS
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-826-0374
Mailing Address - Fax:
Practice Address - Street 1:2060 E. PARIS
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-826-0374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061751208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1689624017OtherINDIVIDUAL NPI #