=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780838763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOVEREIGN PLASTIC SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2008
-----------------------------------------------------
Last Update Date | 10/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 ARLINGTON ST SUITE 112
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-366-5476
-----------------------------------------------------
Fax | 941-866-7388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 ARLINGTON ST SUITE 112
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-366-5476
-----------------------------------------------------
Fax | 941-866-7388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALISSA M SHULMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-366-5476
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | ME103128
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------