Provider Demographics
NPI:1548551815
Name:Y PLASTIC AND RECONSTRUCTIVE SURGERY
Entity type:Organization
Organization Name:Y PLASTIC AND RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASAF
Authorized Official - Middle Name:
Authorized Official - Last Name:YALIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-822-4402
Mailing Address - Street 1:145 TOWNE LAKE PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4847
Mailing Address - Country:US
Mailing Address - Phone:404-822-4402
Mailing Address - Fax:678-739-0041
Practice Address - Street 1:145 TOWNE LAKE PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4847
Practice Address - Country:US
Practice Address - Phone:404-822-4402
Practice Address - Fax:678-739-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061379208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I240012Medicare PIN