Healthcare Provider Details

I. General information

NPI: 1497128953
Provider Name (Legal Business Name): FLEMING ISLAND PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1679 EAGLE HARBOR PKWY SUITE C
FLEMING ISLAND FL
32003-4815
US

IV. Provider business mailing address

1679 EAGLE HARBOR PKWY SUITE C
FLEMING ISLAND FL
32003-4815
US

V. Phone/Fax

Practice location:
  • Phone: 904-348-0727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME107749
License Number StateFL

VIII. Authorized Official

Name: SHANNON DELP
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 904-874-7215