Provider Demographics
NPI:1144322538
Name:CENTER FOR COSMETIC & RECONSTRUCTIVE SURGERY PC
Entity type:Organization
Organization Name:CENTER FOR COSMETIC & RECONSTRUCTIVE SURGERY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FARAMARZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MOVAGHARNIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-951-7595
Mailing Address - Street 1:200 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 590
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5964
Mailing Address - Country:US
Mailing Address - Phone:770-951-7595
Mailing Address - Fax:770-951-7598
Practice Address - Street 1:200 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 590
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5918
Practice Address - Country:US
Practice Address - Phone:770-951-7595
Practice Address - Fax:770-951-7598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043437208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00766983AMedicaid
GA24BCBNJMedicare ID - Type Unspecified
GA00766983AMedicaid