MEDICARE: THE CENTER FOR PLASTIC SURGERY OF NORTHERN MICHIGAN

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	174400000X	Specialist	4301054838	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2402810801	OTHER	MI	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2402810801	OTHER	MI	BLUE CARE NETWORK

General Provider Information

NPI Number	:	1356563654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CENTER FOR PLASTIC SURGERY OF NORTHERN MICHIGAN

Provider Business Mailing Address
First Line	:	4110 COPPER RIDGE DR
Second Line	:	SUITE 242
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-6722
Country	:	US
Telephone Number	:	231-929-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 COPPER RIDGE DR
Second Line	:	SUITE 242
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-6722
Country	:	US
Telephone Number	:	231-929-7700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER JEFFRIES
Credential	:
Telephone Number	:	231-929-7700

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	05/13/2021

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Directions to “THE CENTER FOR PLASTIC SURGERY OF NORTHERN MICHIGAN ” Practice Location

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