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General NPI Number Information
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NPI Number | 1669539078
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Entity Type | Organization
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Legal Business Name | IMAGE PLASTIC SURGERY CENTER, INC
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 682 HEMLOCK ST #410
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City | MACON
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State | GA
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Zip | 31201-6883
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Country | US
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Telephone | 478-745-7925
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Fax | 478-745-7885
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Provider Business Mailing Address
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Address Line | PO BOX 4207
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City | MACON
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State | GA
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Zip | 31208-4207
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Country | US
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Telephone | 478-745-7925
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | OLADIRAN A AFOLABI-BROWN
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Credential | M.D.
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Telephone | 478-745-7925
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number |
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License Number State | GA
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