Basic Information
| Provider Information | |||||||||
| NPI: | 1023060779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLASTIC SURGICAL ASSOCIATES OF PITTSBURGH, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRAGDON-STOFMAN PLASTIC SURGERY GROUP PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 719 | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151460719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4124570175 | ||||||||
| FaxNumber: | 4124570179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 BOWER HILL RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152431800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125726164 | ||||||||
| FaxNumber: | 4125726156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRAGDON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4125726164 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
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 | 1015516860001 | 05 | PA | MEDICAID |