Provider Demographics
NPI:1861579088
Name:RENAISSANCE PLASTIC SURGERY PA
Entity type:Organization
Organization Name:RENAISSANCE PLASTIC SURGERY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FREMD
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-784-4008
Mailing Address - Street 1:398 COPPERFIELD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-784-4008
Mailing Address - Fax:704-784-2060
Practice Address - Street 1:398 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:704-784-4008
Practice Address - Fax:704-784-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36553208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949685Medicaid
NC49685OtherBCBS
NC49685OtherBCBS
NC2187736Medicare PIN