Basic Information
| Provider Information | |||||||||
| NPI: | 1003924770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAMILTON FACIAL PLASTIC SURGERY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68952 | ||||||||
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| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462680952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178706754 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 533 E COUNTY LINE RD | ||||||||
| Address2: | STE 104 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461431073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178593810 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | HAMILTON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3178593810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200887100 | 05 | IN | MEDICAID |