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General NPI Number Information
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NPI Number | 1932807682
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Entity Type | Organization
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Legal Business Name | RESILIENT PLASTIC SURGERY, PLLC
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Dates
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Enumeration Date | 02/22/2023
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Last Update Date | 06/21/2023
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Provider Practice Location Address
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Address Line | 800 8TH AVE STE 116
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City | FORT WORTH
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State | TX
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Zip | 76104-2606
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Country | US
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Telephone | 817-335-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 800 8TH AVE STE 116
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City | FORT WORTH
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State | TX
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Zip | 76104-2606
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PLASTIC & RECONSTRUCTIVE SURGEON
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Name | DR. MICHELLE MARTIN SOUTHARD
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Credential | DO
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Telephone | 817-335-6363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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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 |
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