Provider Demographics
NPI:1780069765
Name:SANTAMARINA AESTHETIC AND PLASTIC SURGERY LLC
Entity type:Organization
Organization Name:SANTAMARINA AESTHETIC AND PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTAMARINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-344-1750
Mailing Address - Street 1:55 PITTSFIELD RD
Mailing Address - Street 2:BUILDING 12C
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2123
Mailing Address - Country:US
Mailing Address - Phone:413-344-1750
Mailing Address - Fax:413-728-8794
Practice Address - Street 1:55 PITTSFIELD RD
Practice Address - Street 2:BUILDING 12C
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2123
Practice Address - Country:US
Practice Address - Phone:413-344-1750
Practice Address - Fax:413-728-8794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219998261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110075931AMedicaid
MA110075931AMedicaid