Healthcare Provider Details

I. General information

NPI: 1285722264
Provider Name (Legal Business Name): PLASTIC SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 RIVER RIDGE DR NE
CEDAR RAPIDS IA
52402-7596
US

IV. Provider business mailing address

3705 RIVER RIDGE DR NE
CEDAR RAPIDS IA
52402-7596
US

V. Phone/Fax

Practice location:
  • Phone: 319-393-1902
  • Fax: 319-393-1867
Mailing address:
  • Phone: 319-393-1902
  • Fax: 319-393-1867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number24782
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0229138
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DR. CHARLES E GRADO
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 319-393-1902