MEDICARE: PHYSICIAN'S INSTITUTE OF COSMETIC AND RECONSTRUCTIVE SURGERY

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
1	174400000X	Specialist	ME64761	FL
2	174400000X	Specialist	ME62894	FL

General Provider Information

NPI Number	:	1770787087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN'S INSTITUTE OF COSMETIC AND RECONSTRUCTIVE SURGERY

Provider Business Mailing Address
First Line	:	3449 JOHNSON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5420
Country	:	US
Telephone Number	:	954-964-4113
Fax Number	:	954-963-8121

Provider Business Practice Location Address
First Line	:	3449 JOHNSON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-5420
Country	:	US
Telephone Number	:	954-964-4113
Fax Number	:	954-963-8121

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. WANDA DITTHARDT
Credential	:
Telephone Number	:	954-964-4113

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	08/22/2020

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