=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841432812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE PLASTIC SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2009
-----------------------------------------------------
Last Update Date | 04/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3543 HIGHWAY 81
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-642-4367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 446
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30086-0446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-642-4367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. EARL STEPHENSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-642-4367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 045975
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------