Healthcare Provider Details

I. General information

NPI: 1194979039
Provider Name (Legal Business Name): PLASTIC SURGERY SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 E. PARIS SUITE 110
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2060 E. PARIS SUITE 110
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-826-0374
  • Fax:
Mailing address:
  • Phone: 616-826-0374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301061751
License Number StateMI

VIII. Authorized Official

Name: ANDREW JOHN LIVINGSTON
Title or Position: OWNER
Credential: M.D.
Phone: 616-826-0374