Healthcare Provider Details

I. General information

NPI: 1720265770
Provider Name (Legal Business Name): PLASTIC SURGICENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 ORNAC JOHN CUMING BUILDING SUITE 510
CONCORD MA
01742
US

IV. Provider business mailing address

131 ORNAC JOHN CUMING BUILDING SUITE 510
CONCORD MA
01742
US

V. Phone/Fax

Practice location:
  • Phone: 978-369-8777
  • Fax: 978-369-5554
Mailing address:
  • Phone: 978-369-8777
  • Fax: 978-369-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number29312
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number29312
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number29312
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number29312
License Number StateMA

VIII. Authorized Official

Name: HYTHO H PANTAZELOS
Title or Position: PLASTIC SURGEON
Credential: MD
Phone: 978-369-8777