Healthcare Provider Details

I. General information

NPI: 1548709314
Provider Name (Legal Business Name): GEORGIA PLASTIC SURGERY SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 PLEASANT HILL RD SUITE #300
DULUTH GA
30096-1407
US

IV. Provider business mailing address

3855 PLEASANT HILL RD SUITE #300
DULUTH GA
30096-1407
US

V. Phone/Fax

Practice location:
  • Phone: 770-418-1234
  • Fax:
Mailing address:
  • Phone: 770-418-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number8264
License Number StateGA

VIII. Authorized Official

Name: MS. KRISTINA LYNNE KAMBURIS
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 205-292-0065