Healthcare Provider Details

I. General information

NPI: 1063549178
Provider Name (Legal Business Name): PLASTIC SURGERY CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 CHADWICK DR SUITE 108
JACKSON MS
39204-3471
US

IV. Provider business mailing address

1920 CHADWICK DR SUITE 108
JACKSON MS
39204-3471
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-3730
  • Fax:
Mailing address:
  • Phone: 601-373-3730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number08261
License Number StateMS

VIII. Authorized Official

Name: MRS. DIANA GORMAN
Title or Position: VICE PRES- OFFICE MANAGER
Credential:
Phone: 601-373-3730