Basic Information
| Provider Information | |||||||||
| NPI: | 1255393971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIEDMONT PLASTIC SURGERY, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1011 N LINDSAY ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368861667 | ||||||||
| FaxNumber: | 3368865536 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N LINDSAY ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272623944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368861667 | ||||||||
| FaxNumber: | 3368865536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLARD | ||||||||
| AuthorizedOfficialFirstName: | VIRGIL | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PLASTIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 3368861667 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7902376 | 05 | NC | MEDICAID |