Provider Demographics
NPI:1902666324
Name:PENINSULA PLASTIC SURGERY MEDICAL GROUP INC
Entity type:Organization
Organization Name:PENINSULA PLASTIC SURGERY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-713-4341
Mailing Address - Street 1:1750 EL CAMINO REAL STE 405
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3217
Mailing Address - Country:US
Mailing Address - Phone:650-692-0467
Mailing Address - Fax:
Practice Address - Street 1:1750 EL CAMINO REAL STE 405
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3217
Practice Address - Country:US
Practice Address - Phone:650-692-0467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty