Healthcare Provider Details

I. General information

NPI: 1174836126
Provider Name (Legal Business Name): SURGICAL RENEWAL & AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CYPRESS CREEK RD SUITE 100
CEDAR PARK TX
78613-3513
US

IV. Provider business mailing address

1900 CYPRESS CREEK RD SUITE 100
CEDAR PARK TX
78613-3513
US

V. Phone/Fax

Practice location:
  • Phone: 512-535-5554
  • Fax: 512-454-5252
Mailing address:
  • Phone: 512-535-5554
  • Fax: 512-454-5252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberN1552
License Number StateTX

VIII. Authorized Official

Name: PAUL ANTHONY BERRY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 512-535-5554