Healthcare Provider Details

I. General information

NPI: 1447619218
Provider Name (Legal Business Name): PURA PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5351 SUNSET BLVD
LEXINGTON SC
29072-9159
US

IV. Provider business mailing address

5351 SUNSET BLVD
LEXINGTON SC
29072-9159
US

V. Phone/Fax

Practice location:
  • Phone: 803-490-7644
  • Fax: 803-490-7645
Mailing address:
  • Phone: 803-490-7644
  • Fax: 803-490-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number33186
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number33186
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number33186
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number33186
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number33186
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number33186
License Number StateSC

VIII. Authorized Official

Name: OLIVER POPE SIMMONS
Title or Position: OWNER
Credential: MD
Phone: 803-421-9208