Healthcare Provider Details

I. General information

NPI: 1134356991
Provider Name (Legal Business Name): PLASTIC SURGERY OF JUPITER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MILITARY TRL SUITE 202
JUPITER FL
33458-4810
US

IV. Provider business mailing address

4600 MILITARY TRL SUITE 202
JUPITER FL
33458-4810
US

V. Phone/Fax

Practice location:
  • Phone: 561-748-1565
  • Fax: 561-748-1568
Mailing address:
  • Phone: 561-748-1565
  • Fax: 561-748-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberME75895
License Number StateFL

VIII. Authorized Official

Name: KIM EDWARD KOGER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 561-748-1565