Healthcare Provider Details

I. General information

NPI: 1336546449
Provider Name (Legal Business Name): PLASTIC SURGERY ASSOCIATES OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 MERIDIAN MARKS RD SUITE 395
ATLANTA GA
30342-4763
US

IV. Provider business mailing address

5445 MERIDIAN MARKS RD SUITE 395
ATLANTA GA
30342-4763
US

V. Phone/Fax

Practice location:
  • Phone: 470-440-1777
  • Fax: 678-809-5001
Mailing address:
  • Phone: 470-440-1777
  • Fax: 678-809-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number72195
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number72195
License Number StateGA

VIII. Authorized Official

Name: NELSON CASTILLO
Title or Position: MANAGER
Credential: MD
Phone: 770-317-9330