Healthcare Provider Details

I. General information

NPI: 1053506980
Provider Name (Legal Business Name): CENTER FOR PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7033 SAINT ANDREWS RD SUITE 204
COLUMBIA SC
29212-1179
US

IV. Provider business mailing address

P.O. BOX 11226
COLUMBIA SC
29211-1226
US

V. Phone/Fax

Practice location:
  • Phone: 803-732-5788
  • Fax: 803-932-9618
Mailing address:
  • Phone: 803-732-5788
  • Fax: 803-932-9618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number13063
License Number StateSC

VIII. Authorized Official

Name: PETER C HAINES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 803-732-5788