Provider Demographics
NPI:1285722264
Name:PLASTIC SURGICAL CENTER
Entity type:Organization
Organization Name:PLASTIC SURGICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-393-1902
Mailing Address - Street 1:3705 RIVER RIDGE DR NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-7596
Mailing Address - Country:US
Mailing Address - Phone:319-393-1902
Mailing Address - Fax:319-393-1867
Practice Address - Street 1:3705 RIVER RIDGE DR NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-7596
Practice Address - Country:US
Practice Address - Phone:319-393-1902
Practice Address - Fax:319-393-1867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24782208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0229138Medicaid
IA22913Medicare PIN
IA22913Medicare ID - Type Unspecified
IAA02741Medicare UPIN