Basic Information
| Provider Information | |||||||||
| NPI: | 1710916960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE NORMAN PLASTIC SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15133 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277040133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194775152 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Practice Location | |||||||||
| Address1: | LAKE NORMAN MEDICAL & PROFESSIONAL PLAZA, SUITE 106 | ||||||||
| Address2: | 146 MEDICAL PARK RD. | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046589921 | ||||||||
| FaxNumber: | 7046589928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | RAVIN | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7046589921 | ||||||||
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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 | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DO2646 | 01 | NC | RAILROAD MEDICARE | OTHER | P00667059 | 01 | NC | RAILROAD MEDICARE | OTHER | 143AR | 01 | NC | BLUE CROSS AND BLUE SHIEL | OTHER |