Basic Information
| Provider Information | |||||||||
| NPI: | 1770554800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKINGHAM CENTER FOR FACIAL PLASTIC SURGERY PA | ||||||||
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| OtherOrganizationName: | BUCKINGHAM FACIAL PLASTIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2745 BEE CAVES RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787465640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124012500 | ||||||||
| FaxNumber: | 5124012501 | ||||||||
| Practice Location | |||||||||
| Address1: | 2745 BEE CAVES RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124012500 | ||||||||
| FaxNumber: | 5124012501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUCKINGHAM | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | DEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5124012500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | K5468 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207Y00000X | K5468 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0123X | K5468 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0007X | K5468 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 0003NL | 01 | TX | BCBS OF TEXAS GROUP # | OTHER | 170520401 | 05 | TX | MEDICAID |