Provider Demographics
NPI:1386995470
Name:PLASTIC SURGERY OF GWINNETT PC
Entity type:Organization
Organization Name:PLASTIC SURGERY OF GWINNETT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:ROSENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-682-3375
Mailing Address - Street 1:575 PROFESSIONAL DR STE 285
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3355
Mailing Address - Country:US
Mailing Address - Phone:770-682-3375
Mailing Address - Fax:770-682-3387
Practice Address - Street 1:575 PROFESSIONAL DR STE 285
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3355
Practice Address - Country:US
Practice Address - Phone:770-682-3375
Practice Address - Fax:770-682-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039926174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
40BBBBDOtherPTAN
G00155Medicare UPIN