Healthcare Provider Details

I. General information

NPI: 1336238591
Provider Name (Legal Business Name): CHATHAM FACIAL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 STATE STREET SUITE 144
NEW ALBANY IN
47150
US

IV. Provider business mailing address

1919 STATE ST SUITE 144
NEW ALBANY IN
47150-4929
US

V. Phone/Fax

Practice location:
  • Phone: 812-945-3223
  • Fax:
Mailing address:
  • Phone: 812-945-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number23772
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number01034016
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number23772
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number01034016
License Number StateIN

VIII. Authorized Official

Name: MRS. FAYTH BREEDING
Title or Position: OFFICE MANAGER
Credential:
Phone: 812-945-3223