Healthcare Provider Details

I. General information

NPI: 1154342350
Provider Name (Legal Business Name): RENAISSANCE PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE STE 401
PADUCAH KY
42003-3827
US

IV. Provider business mailing address

2601 KENTUCKY AVE STE 401
PADUCAH KY
42003
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-8200
  • Fax: 270-444-8398
Mailing address:
  • Phone: 270-444-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL M TKACH
Title or Position: OWNER
Credential: M.D.
Phone: 270-444-8200