Provider Demographics
NPI:1194997262
Name:TRAIKOVICH COSMETIC SURGERY, P.C.
Entity type:Organization
Organization Name:TRAIKOVICH COSMETIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:TRAIKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-317-9347
Mailing Address - Street 1:9967 E DESERT BEAUTY DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-2579
Mailing Address - Country:US
Mailing Address - Phone:602-317-9347
Mailing Address - Fax:
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:STE 206
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4015
Practice Address - Country:US
Practice Address - Phone:623-516-0930
Practice Address - Fax:623-580-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-29
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG85621Medicare UPIN
AZZ71703Medicare PIN