Provider Demographics
NPI:1538363825
Name:PLASTIC SURGERY CLINIC OF JACKSON, PC
Entity type:Organization
Organization Name:PLASTIC SURGERY CLINIC OF JACKSON, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:R
Authorized Official - Last Name:YELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-668-2490
Mailing Address - Street 1:10 LYNOAK CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2800
Mailing Address - Country:US
Mailing Address - Phone:731-668-2490
Mailing Address - Fax:731-664-4374
Practice Address - Street 1:10 LYNOAK CV
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2800
Practice Address - Country:US
Practice Address - Phone:731-668-2490
Practice Address - Fax:731-664-4374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3381722Medicare PIN
TN3824296Medicare PIN
G01860Medicare UPIN