Healthcare Provider Details

I. General information

NPI: 1063783660
Provider Name (Legal Business Name): ELAN PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WORMANS MILL CT STE L-M
FREDERICK MD
21701-3019
US

IV. Provider business mailing address

15 WORMANS MILL CT STE L-M
FREDERICK MD
21701-3019
US

V. Phone/Fax

Practice location:
  • Phone: 301-698-2400
  • Fax: 301-698-2460
Mailing address:
  • Phone: 301-698-2400
  • Fax: 301-698-2460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberD0037204
License Number StateMD

VIII. Authorized Official

Name: PAIGE SMITH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 301-509-4091