Healthcare Provider Details

I. General information

NPI: 1033212170
Provider Name (Legal Business Name): PLASTIC & RECONSTRUCTIVE SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SCHOOL STREET SUITE 305
PAWTUCKET RI
02860
US

IV. Provider business mailing address

333 SCHOOL STREET SUITE 305
PAWTUCKET RI
02860
US

V. Phone/Fax

Practice location:
  • Phone: 401-728-7950
  • Fax: 401-729-7952
Mailing address:
  • Phone: 401-728-7950
  • Fax: 401-729-7952

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: CHARLES F JOHNSON
Title or Position: PRESIDENT
Credential: MD
Phone: 401-728-7950