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General NPI Number Information
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NPI Number | 1609958776
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Entity Type | Organization
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Legal Business Name | SOUTHWEST VIRGINIA CENTER FOR COSMETIC PLASTIC & RECON SURGERY
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 04/11/2011
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Provider Practice Location Address
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Address Line | 2965 COLONNADE DRIVE SUITE 140
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City | ROANOKE
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State | VA
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Zip | 24018-3541
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Country | US
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Telephone | 540-989-6361
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Fax | 540-989-6361
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Provider Business Mailing Address
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Address Line | 2965 COLONNADE DRIVE SUITE 140
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City | ROANOKE
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State | VA
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Zip | 24018-3541
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Country | US
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Telephone | 540-989-6361
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Fax | 540-989-8697
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL J BREINER
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Credential | M.D.
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Telephone | 540-989-6361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101050226
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 0101050226
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License Number State | VA
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