Provider Demographics
NPI:1144282336
Name:GREENVILLE PLASTIC SURGERY, PA
Entity type:Organization
Organization Name:GREENVILLE PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCLAWHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-758-6627
Mailing Address - Street 1:400 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7244
Mailing Address - Country:US
Mailing Address - Phone:252-758-6627
Mailing Address - Fax:252-830-5168
Practice Address - Street 1:400 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7244
Practice Address - Country:US
Practice Address - Phone:252-758-6627
Practice Address - Fax:252-830-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0146NOtherBCBS GROUP ID #
NC890146NMedicaid
NC2318800Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER