Healthcare Provider Details

I. General information

NPI: 1396095568
Provider Name (Legal Business Name): CASCADE PLASTIC SURGERY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 FOURTH ST
JACKSON MI
49203-4032
US

IV. Provider business mailing address

1514 FOURTH ST
JACKSON MI
49203-4032
US

V. Phone/Fax

Practice location:
  • Phone: 517-780-0080
  • Fax:
Mailing address:
  • Phone: 517-780-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301049181
License Number StateMI

VIII. Authorized Official

Name: JOHN ARGYLE GILMORE SAMPSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 517-780-0080