Healthcare Provider Details

I. General information

NPI: 1396228995
Provider Name (Legal Business Name): PENINSULA PLASTIC SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N MAIN ST STE D
BERLIN MD
21811-1060
US

IV. Provider business mailing address

314 W CARROLL ST STE 1
SALISBURY MD
21801-5409
US

V. Phone/Fax

Practice location:
  • Phone: 410-546-0464
  • Fax:
Mailing address:
  • Phone: 410-546-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VINCENT J PERROTTA
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 410-546-0464