Basic Information
| Provider Information | |||||||||
| NPI: | 1548268535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSHORE PLASTIC SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5087988012 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 CENTENNIAL DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019607935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785316966 | ||||||||
| FaxNumber: | 9785312221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WAGES | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9785316966 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9707573 | 05 | MA | MEDICAID |