Healthcare Provider Details

I. General information

NPI: 1093808388
Provider Name (Legal Business Name): FAYETTEVILLE PLASTIC SURGERY SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1774 METROMEDICAL DR
FAYETTEVILLE NC
28304-3861
US

IV. Provider business mailing address

1774 METROMEDICAL DR
FAYETTEVILLE NC
28304-3861
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1203
  • Fax: 910-483-1130
Mailing address:
  • Phone: 910-323-1203
  • Fax: 910-483-1130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number27390
License Number StateNC

VIII. Authorized Official

Name: DR. HORACE WILLIAM MILLER IV
Title or Position: PRESIDENT
Credential: MD
Phone: 910-323-1203