Healthcare Provider Details

I. General information

NPI: 1356805402
Provider Name (Legal Business Name): SR PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CORNWALL DR UNIT B2
EAST BRUNSWICK NJ
08816
US

IV. Provider business mailing address

9 MOUNTHAVEN DR
LIVINGSTON NJ
07039-2711
US

V. Phone/Fax

Practice location:
  • Phone: 617-233-9928
  • Fax:
Mailing address:
  • Phone: 617-233-9928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KANDICE KING
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 847-228-3303