Provider Demographics
NPI:1992759997
Name:SUBURBAN PLASTIC SURGEONS PC
Entity type:Organization
Organization Name:SUBURBAN PLASTIC SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-572-6888
Mailing Address - Street 1:1250 GREENWOOD AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2902
Mailing Address - Country:US
Mailing Address - Phone:215-572-6888
Mailing Address - Fax:215-572-5905
Practice Address - Street 1:1250 GREENWOOD AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2902
Practice Address - Country:US
Practice Address - Phone:215-572-6888
Practice Address - Fax:215-572-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043562L208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0016511000OtherKEYSTONE HEALTH PLAN
052949OtherBLUE SHIELD
052949OtherPERSONAL CHOICE
PA0018274790004Medicaid
052949OtherPERSONAL CHOICE
G28713Medicare UPIN
PA0018274790004Medicaid