Provider Demographics
NPI:1245499276
Name:VIRGINIA INSTITUTE OF PLASTIC SURGERY PC
Entity type:Organization
Organization Name:VIRGINIA INSTITUTE OF PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-290-0909
Mailing Address - Street 1:7611 FOREST AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4920
Mailing Address - Country:US
Mailing Address - Phone:804-290-0909
Mailing Address - Fax:804-290-0333
Practice Address - Street 1:7611 FOREST AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4920
Practice Address - Country:US
Practice Address - Phone:804-290-0909
Practice Address - Fax:804-290-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236442208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1245499276Medicaid
VAC10523Medicare PIN