Basic Information
| Provider Information | |||||||||
| NPI: | 1760777684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOREALIS PLASTIC SURGERY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4977 SKYVIEW CT | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496846941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314216599 | ||||||||
| FaxNumber: | 2314216602 | ||||||||
| Practice Location | |||||||||
| Address1: | 4977 SKYVIEW CT | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496846941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314216599 | ||||||||
| FaxNumber: | 2314216602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | BRYANT | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2314216599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 4301084224 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No ID Information.