Provider Demographics
NPI:1396991675
Name:PENINSULA PLASTIC SURGERY, P.C.
Entity type:Organization
Organization Name:PENINSULA PLASTIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-546-0464
Mailing Address - Street 1:314 W CARROLL ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5409
Mailing Address - Country:US
Mailing Address - Phone:410-546-0464
Mailing Address - Fax:410-546-8529
Practice Address - Street 1:20930 DUPONT BLVD
Practice Address - Street 2:201 GRAY STONE TOWERS
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-1725
Practice Address - Country:US
Practice Address - Phone:410-546-0464
Practice Address - Fax:410-546-8529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1997115585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG00029Medicare PIN
DEG00902Medicare Oscar/Certification