Fleming Island Plastic Surgery LLC

Primary specialty

Plastic and Reconstructive Surgery PhysicianTaxonomy code 2086S0122X

License

ME107749 Issued in FL

Legal business name

FLEMING ISLAND PLASTIC SURGERY LLC

Practice address

1715 Eagle Harbor Pkwy Ste B
Fleming Island, FL 32003-4324

Phone

(904) 990-3477

Fax

(904) 621-9272

NPI assigned

Oct 21, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. William Wallace, MDNPI 1184842627

Title

Manager/Owner

Phone

(904) 990-3477

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Fleming Island Plastic Surgery LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Fleming Island Plastic Surgery LLC

  • Plastic Surgery Physician
  • Fleming Island, FL
  • NPI 1497128953
  NPD tax ID

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• William Arthur Wallace Jr., M.D.

  • Plastic and Reconstructive Surgery Physician
  • Fleming Island, FL
  • NPI 1184842627
  Medicare reassignment Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1445385600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1726185600000",
    "number": "1245602069",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "916 ALAMEDA LN",
            "city": "SAINT JOHNS",
            "state": "FL",
            "postal_code": "322596903",
            "telephone_number": "904-348-0727",
            "fax_number": "904-621-9272"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1715 EAGLE HARBOR PKWY STE B",
            "city": "FLEMING ISLAND",
            "state": "FL",
            "postal_code": "320034324",
            "telephone_number": "904-990-3477",
            "fax_number": "904-621-9272"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FLEMING ISLAND PLASTIC SURGERY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-21",
        "last_updated": "2024-09-13",
        "certification_date": "2024-09-13",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "MANAGER/OWNER",
        "authorized_official_telephone_number": "904-990-3477",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2086S0122X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": "FL",
            "license": "ME107749",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Fleming Island Pharmacy LLC (Fleming Island Pharmacy)
• Fleming Island Plastic Surgery LLC
• Fleming Island Vision Center, Inc. (Pearle Vision of Fleming Island)
• Florida Cancer Specialists & Research Institute, LLC (Florida Cancer Specialists)
• Florida Department of Health
• Florida Physician Specialists LLC (Advanced Prostate Cancer Institute)

• Plastic and Reconstructive Surgery Physician in Fleming Island, FL
• Providers in Fleming Island, FL by specialty
• Plastic and Reconstructive Surgery Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.