Organization
MEDICAL COSMETIC CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA HASTETTER (PRACTICE MANAGER)
(812) 476-6161
Entity
Organization
Contact information
Practice address
7145 E VIRGINIA ST, SUITE 2000, EVANSVILLE, IN 47715-9124
(812) 476-6161
(812) 476-6162
Mailing address
7145 E VIRGINIA ST, SUITE 2000, EVANSVILLE, IN 47715-9124
(812) 476-6161
(812) 476-6162
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
01062143A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11564440
PROVIDER CAQH NUMBER
IN
Enumeration date
03/09/2007
Last updated
10/16/2007
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