Healthcare Provider Details

I. General information

NPI: 1568667624
Provider Name (Legal Business Name): PLASTIKOS SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 GEORGETOWN SQUARE
ATLANTA GA
30338-6205
US

IV. Provider business mailing address

4370 GEORGETOWN SQUARE
ATLANTA GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-4677
  • Fax: 678-514-2104
Mailing address:
  • Phone: 678-514-2108
  • Fax: 678-514-2104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. FELICIA A WILSON
Title or Position: MANAGER CBO
Credential:
Phone: 678-514-2108