Provider Demographics
NPI:1699961193
Name:PLASTIC SURGERY & WEIGHT LOSS CNTR
Entity type:Organization
Organization Name:PLASTIC SURGERY & WEIGHT LOSS CNTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-239-0079
Mailing Address - Street 1:PO BOX 8781
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-8781
Mailing Address - Country:US
Mailing Address - Phone:417-239-0079
Mailing Address - Fax:417-239-1228
Practice Address - Street 1:10994 HISTORIC HIGHWAY 165 STE D
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-5606
Practice Address - Country:US
Practice Address - Phone:417-239-0079
Practice Address - Fax:417-239-1228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101644261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODD0320OtherRAILROAD MEDICARE
MO244744504Medicaid
MO10014MOtherBLUE SHIELD NON-PART
MO21186039OtherBLUE SHIELD OF KC
MO244744504Medicaid
MO244744504Medicaid