Basic Information
| Provider Information | |||||||||
| NPI: | 1891976650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CENTERS FOR PLASTIC SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240150127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409819394 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 KEAGY RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404444343 | ||||||||
| FaxNumber: | 5404444345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | WRAY | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5404444343 | ||||||||
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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 | 208200000X | 0101042617 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | C10337 | 01 | VA | MEDICARE GROUP | OTHER |