Healthcare Provider Details

I. General information

NPI: 1073505129
Provider Name (Legal Business Name): PLASTIC SURGERY CENTRE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 CONSTITUTION LN
DANVERS MA
01923-3694
US

IV. Provider business mailing address

85 CONSTITUTION LN
DANVERS MA
01923-3694
US

V. Phone/Fax

Practice location:
  • Phone: 978-777-5557
  • Fax: 978-777-1615
Mailing address:
  • Phone: 978-777-5557
  • Fax: 978-777-1615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number StateMA

VIII. Authorized Official

Name: JOHN P WYSOCKI
Title or Position: PRESIDENT
Credential: MD
Phone: 978-777-5557