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General NPI Number Information
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NPI Number | 1982854568
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Entity Type | Organization
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Legal Business Name | STATESBORO PLASTIC SURGERY
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Dates
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Enumeration Date | 09/19/2008
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Last Update Date | 10/16/2012
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Provider Practice Location Address
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Address Line | 1402 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458
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Country | US
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Telephone | 912-681-3330
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Fax | 912-681-3303
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Provider Business Mailing Address
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Address Line | 1402 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458
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Country | US
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Telephone | 912-681-3330
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Fax | 912-681-3303
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | MARK E BISSECK
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Credential | M.D.
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Telephone | 912-681-3330
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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 | 061556
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License Number State | GA
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