Healthcare Provider Details

I. General information

NPI: 1710084827
Provider Name (Legal Business Name): CENTER FOR PLASTIC & RECONSTRUCTIVE SURGERY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 ASHLEY ST STE 303
BOWLING GREEN KY
42103-2451
US

IV. Provider business mailing address

1048 ASHLEY ST STE 303
BOWLING GREEN KY
42103-2451
US

V. Phone/Fax

Practice location:
  • Phone: 270-796-8960
  • Fax: 270-842-5683
Mailing address:
  • Phone: 270-796-8960
  • Fax: 270-842-5683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number33744
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FOUAD V ATALLA
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 270-796-8960