Basic Information
| Provider Information | |||||||||
| NPI: | 1992877088 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FACIAL PLASTIC & RECONSTRUCTIVE SURGERY SPECIALISTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27015 | ||||||||
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| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681270015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023939459 | ||||||||
| FaxNumber: | 4023979895 | ||||||||
| Practice Location | |||||||||
| Address1: | 7373 FRANCE AVE S | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554354534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528440404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | DINVILLE | ||||||||
| AuthorizedOfficialFirstName: | JYL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN CODING & REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4023975462 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0099X | 23875 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck |
ID Information
| ID | Type | State | Issuer | Description | HP13518 | 01 | HEALTHPARTNERS | OTHER | 34040 | 01 | HEALTHPARTNERS | OTHER | 1300010 | 01 | MEDICA CHOICE | OTHER |