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NPI Code Detail

MEDICARE: BOREALIS PLASTIC SURGERY, PLLC

MEDICARE: BOREALIS PLASTIC SURGERY, PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12086S0122XPlastic and Reconstructive Surgery Physician4301084224MI

General Provider Information

NPI Number : 1760777684
Entity Type Code : Organization
Provider Name (Legal Business Name) : BOREALIS PLASTIC SURGERY, PLLC
Provider Business Mailing Address
First Line : 4977 SKYVIEW CT
Second Line :
City : TRAVERSE CITY
State : MI
Zip : 49684-6941
Country : US
Telephone Number : 231-421-6599
Fax Number : 231-421-6602
Provider Business Practice Location Address
First Line : 4977 SKYVIEW CT
Second Line :
City : TRAVERSE CITY
State : MI
Zip : 49684-6941
Country : US
Telephone Number : 231-421-6599
Fax Number : 231-421-6602
Authorized Official
Title or Position : PHYSICIAN
Name : DR. ADAM BRYANT SMITH
Credential : MD
Telephone Number : 231-421-6599
Provider Enumeration Date : 06/20/2011
Last Update Date : 08/03/2011

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Directions to “BOREALIS PLASTIC SURGERY, PLLC ” Practice Location

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