Healthcare Provider Details

I. General information

NPI: 1124003306
Provider Name (Legal Business Name): NORTHEAST PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 MAIN ST
LEWISTON ME
04240-7054
US

IV. Provider business mailing address

287 MAIN ST
LEWISTON ME
04240-7054
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-6543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN BONAWITZ
Title or Position: PRESIDENT
Credential: MD
Phone: 207-795-6543