Basic Information
| Provider Information | |||||||||
| NPI: | 1114960358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACKHAWK PLASTIC SURGERY, A MEDICAL CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD | ||||||||
| Address2: | STE 440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104403131 | ||||||||
| FaxNumber: | 3104729582 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 BLACKHAWK PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945064623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257365757 | ||||||||
| FaxNumber: | 9257365763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | RONAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9257365757 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |
No ID Information.