Provider Demographics
NPI:1174973606
Name:SHAW PLASTIC SURGERY, LLC
Entity type:Organization
Organization Name:SHAW PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-440-9801
Mailing Address - Street 1:3595 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8168
Mailing Address - Country:US
Mailing Address - Phone:316-440-9801
Mailing Address - Fax:316-440-9701
Practice Address - Street 1:3595 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8168
Practice Address - Country:US
Practice Address - Phone:316-440-9801
Practice Address - Fax:316-440-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSG06307Medicare UPIN