Provider Demographics
NPI:1053428409
Name:SIMI VALLEY CENTER FOR PLASTIC SURGERY
Entity type:Organization
Organization Name:SIMI VALLEY CENTER FOR PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FEALY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-579-0821
Mailing Address - Street 1:2435 SPRINGBROOK ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1147
Mailing Address - Country:US
Mailing Address - Phone:805-579-0821
Mailing Address - Fax:
Practice Address - Street 1:2750 SYCAMORE DR STE 200
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1500
Practice Address - Country:US
Practice Address - Phone:805-579-0821
Practice Address - Fax:805-579-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF16274Medicare UPIN
CAW18236Medicare ID - Type Unspecified