Provider Demographics
NPI:1548268535
Name:NORTHSHORE PLASTIC SURGERY, LLC
Entity type:Organization
Organization Name:NORTHSHORE PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-531-6966
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:STE. 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-798-8012
Practice Address - Street 1:4 CENTENNIAL DR
Practice Address - Street 2:STE 102
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7935
Practice Address - Country:US
Practice Address - Phone:978-531-6966
Practice Address - Fax:978-531-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9707573Medicaid
MAM21318Medicare ID - Type Unspecified