Basic Information
| Provider Information | |||||||||
| NPI: | 1730380775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST SIDE PLASTIC SURGERY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4480 S COBB DR SE STE H | ||||||||
| Address2: | BOX 323 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300806984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048055535 | ||||||||
| FaxNumber: | 8669355995 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 JOHNSON FERRY RD N.E. | ||||||||
| Address2: | SUITE 336 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048055535 | ||||||||
| FaxNumber: | 8669355995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | GIPSON | ||||||||
| AuthorizedOfficialFirstName: | VETRA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4048050646 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 50518 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000963102B | 05 | GA | MEDICAID |