Provider Demographics
NPI:1962793505
Name:SOUTHEASTERN AESTHETIC SURGERY, LLC
Entity type:Organization
Organization Name:SOUTHEASTERN AESTHETIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-310-1668
Mailing Address - Street 1:4115 COLUMBIA RD
Mailing Address - Street 2:SUITE 5331
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0405
Mailing Address - Country:US
Mailing Address - Phone:561-310-1668
Mailing Address - Fax:
Practice Address - Street 1:447 N BELAIR RD
Practice Address - Street 2:SUITE 105
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3090
Practice Address - Country:US
Practice Address - Phone:561-310-1668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-01
Last Update Date:2011-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59595208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty