MEDICARE: LADIES PLASTIC SURGERY CENTER PA

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	F5194	TX

General Provider Information

NPI Number	:	1609976653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADIES PLASTIC SURGERY CENTER PA

Provider Business Mailing Address
First Line	:	12801 MIDWAY RD
Second Line	:	SUITE 217
City	:	DALLAS
State	:	TX
Zip	:	75244-6813
Country	:	US
Telephone Number	:	214-361-5070
Fax Number	:	972-241-5075

Provider Business Practice Location Address
First Line	:	12801 MIDWAY RD
Second Line	:	SUITE 217
City	:	DALLAS
State	:	TX
Zip	:	75244-6813
Country	:	US
Telephone Number	:	214-361-5070
Fax Number	:	972-241-5075

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TERESA MARIE ELLIOTT
Credential	:	M.D.
Telephone Number	:	972-241-5083

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	01/16/2008

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