MEDICARE: CAPITAL REGION COSMETIC SURGERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1346991270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITAL REGION COSMETIC SURGERY, LLC

Provider Business Mailing Address
First Line	:	5 ULENSKI DR
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12205-1103
Country	:	US
Telephone Number	:	518-724-2444
Fax Number	:	518-724-2445

Provider Business Practice Location Address
First Line	:	5 ULENSKI DR
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12205-1103
Country	:	US
Telephone Number	:	518-724-2444
Fax Number	:	518-724-2445

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	SUSAN K STREET
Credential	:
Telephone Number	:	518-724-2444

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	06/22/2022

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