=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104005776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PLASTIC SURGEONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13660 BRAEBURN LN
-----------------------------------------------------
City | NOVELTY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44072-9597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-219-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13660 BRAEBURN LN
-----------------------------------------------------
City | NOVELTY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44072-9597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-219-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT T. STROUP
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 216-219-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35 059617
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------