Provider Demographics
NPI:1730218074
Name:FACIAL PLASTIC, RECONSTRUCTIVE & LASER SURGERY, PLLC
Entity type:Organization
Organization Name:FACIAL PLASTIC, RECONSTRUCTIVE & LASER SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANOJ
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:845-454-8025
Mailing Address - Street 1:82 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1721
Mailing Address - Country:US
Mailing Address - Phone:845-454-8025
Mailing Address - Fax:845-454-8026
Practice Address - Street 1:82 N WATER ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1721
Practice Address - Country:US
Practice Address - Phone:845-454-8025
Practice Address - Fax:845-454-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211519207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7539468OtherAETNA PPO POS
NY000415207001OtherHEALTHNOW
NY10074336OtherCDPHP
NY363203OtherMVP PLASTIC
NYP3063915OtherOXFORD LIBERTY, FREEDOM
NY3289877OtherAETNA HMO
NY362957OtherMVP ENT
NY7M7521OtherBLUE CROSS BLUE SHIELD
NY7M7521OtherBLUE CROSS BLUE SHIELD
NYH66925Medicare UPIN