Provider Demographics
NPI:1902887300
Name:PLASTIC SURGERY CENTER INC
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER OF FACILITY
Authorized Official - Prefix:
Authorized Official - First Name:SUDARSHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACS
Authorized Official - Phone:586-263-6050
Mailing Address - Street 1:16100 19 MILE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1148
Mailing Address - Country:US
Mailing Address - Phone:586-263-9657
Mailing Address - Fax:586-263-0436
Practice Address - Street 1:16100 19 MILE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1148
Practice Address - Country:US
Practice Address - Phone:586-263-9657
Practice Address - Fax:586-263-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE01483OtherBCBS
MIZ40007538OtherRAILROAD MEDICARE
MIE01483OtherBCBS
MION36300Medicare ID - Type Unspecified