Provider Demographics
NPI:1992877088
Name:FACIAL PLASTIC & RECONSTRUCTIVE SURGERY SPECIALISTS PA
Entity type:Organization
Organization Name:FACIAL PLASTIC & RECONSTRUCTIVE SURGERY SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN CODING & REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DINVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-397-5462
Mailing Address - Street 1:PO BOX 27015
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-0015
Mailing Address - Country:US
Mailing Address - Phone:402-393-9459
Mailing Address - Fax:402-397-9895
Practice Address - Street 1:7373 FRANCE AVE S
Practice Address - Street 2:SUITE 410
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4534
Practice Address - Country:US
Practice Address - Phone:952-844-0404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN238752082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP13518OtherHEALTHPARTNERS
34040OtherHEALTHPARTNERS
1300010OtherMEDICA CHOICE
MNGROUP # PENDINGMedicare ID - Type Unspecified
HP13518OtherHEALTHPARTNERS
MN040000272Medicare PIN