Provider Demographics
NPI:1215167580
Name:PLASTIC AND RECONSTRUCTIVE SURGERY PC
Entity type:Organization
Organization Name:PLASTIC AND RECONSTRUCTIVE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:DELEGATED OFFICIAL
Authorized Official - Phone:423-328-9000
Mailing Address - Street 1:1303 SUNSET DR STE 5
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7905
Mailing Address - Country:US
Mailing Address - Phone:423-328-9000
Mailing Address - Fax:423-328-9007
Practice Address - Street 1:1303 SUNSET DR STE 5
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7905
Practice Address - Country:US
Practice Address - Phone:423-328-9000
Practice Address - Fax:423-328-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025117173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3081165Medicaid
TN3081165Medicaid
TNB41959Medicare UPIN