MEDICARE: SOUTHPOINT PLASTIC SURGERY, PC

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	2008-01037	NC

General Provider Information

NPI Number	:	1669629903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHPOINT PLASTIC SURGERY, PC

Provider Business Mailing Address
First Line	:	1415 W NC HIGHWAY 54
Second Line	:	SUITE 105
City	:	DURHAM
State	:	NC
Zip	:	27707-5577
Country	:	US
Telephone Number	:	919-806-8866
Fax Number	:	919-806-8877

Provider Business Practice Location Address
First Line	:	1415 W NC HIGHWAY 54
Second Line	:	SUITE 105
City	:	DURHAM
State	:	NC
Zip	:	27707-5577
Country	:	US
Telephone Number	:	919-806-8866
Fax Number	:	919-806-8877

Authorized Official
Title or Position	:	DIRECTOR / PRESIDENT
Name	:	DR. EDWARD RAY
Credential	:	M.D.
Telephone Number	:	919-806-8866

Provider Enumeration Date	:	08/19/2008
Last Update Date	:	04/07/2015

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