Provider Demographics
NPI:1316090574
Name:PLASTIC SURGERY INSTITUTE, PA
Entity type:Organization
Organization Name:PLASTIC SURGERY INSTITUTE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-224-1859
Mailing Address - Street 1:1 LILE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6239
Mailing Address - Country:US
Mailing Address - Phone:501-224-1859
Mailing Address - Fax:501-975-2242
Practice Address - Street 1:1 LILE CT STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6239
Practice Address - Country:US
Practice Address - Phone:501-224-1859
Practice Address - Fax:501-975-2242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140138001Medicaid
AR5G129OtherMEDICARE PTAN