| Name: | University Plastic Surgeons, Inc. |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Dissolved |
| Date of Organization in Rhode Island: | 04 Oct 1983 (41 years ago) |
| Date of Dissolution: | 31 Dec 2020 (4 years ago) |
| Date of Status Change: | 31 Dec 2020 (4 years ago) |
| Identification Number: | 000002383 |
| ZIP code: | 02818 |
| County: | Kent County |
| Principal Address: | 75 FOX RUN, EAST GREENWICH, RI, 02818, USA |
| Purpose: | PRACTICE OF MEDICINE |
| NAICS: | 621112 - Offices of Physicians, Mental Health Specialists |
| Fictitious names: |
University Craniofacial Surgery Associates (trading name, 2011-07-05 - ) University Hand Surgery Associates (trading name, 2007-10-15 - ) University Plastic Surgery Associates (trading name, 1997-12-08 - ) University Plastic Surgeons, Inc. (trading name, 1992-09-23 - 1996-02-28) |
| Historical names: |
Jack R. Bevivino, D.D.S., M.D., Ltd. Jack R. Bevivino, M.D., Ltd. |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1093882615 | 2006-11-29 | 2020-08-22 | 120 DUDLEY STREET, SUITE #201, PROVIDENCE, RI, 02905, US | 120 DUDLEY STREET, SUITE #201, PROVIDENCE, RI, 02905, US | |||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||
| Phone | +1 401-521-9290 |
| Fax | 4015219297 |
Authorized person
| Name | JACK R BEVIVINO |
| Role | PRESIDENT |
| Phone | 4015219290 |
Taxonomy
| Taxonomy Code | 208200000X - Plastic Surgery Physician |
| License Number | RIMD05259 |
| State | RI |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 9002112 |
| State | RI |
| Issuer | UNITED HEALTH CARE |
| Number | 1300124 |
| State | RI |
| Issuer | BCBS |
| Number | 21126 |
| State | RI |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| UNIVERSITY PLASTIC SURGEONS, INC. PROFIT SHARING PLAN | 2009 | 050404640 | 2010-07-29 | UNIVERSITY PLASTIC SURGEONS, INC. | 3 | |||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||
| Administrator’s EIN | 050404640 |
| Plan administrator’s name | UNIVERSITY PLASTIC SURGEONS, INC. |
| Plan administrator’s address | 120 DUDLEY STREET, PROVIDENCE, RI, 02905 |
| Administrator’s telephone number | 4015219290 |
Signature of
| Role | Plan administrator |
| Date | 2010-07-29 |
| Name of individual signing | JACK R. BEVIVINO, M.D. |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| CONSTANCE D. BEVIVINO | Agent | 75 FOX RUN, EAST GREENWICH, RI, 02818, USA |
| Name | Role | Address |
|---|---|---|
| JACK BEVIVINO | PRESIDENT | 12551 WALDEN RUN DRIVE FORT MYERS, FL 33913 USA |
| Type | Date | Old Value | New Value |
|---|---|---|---|
| Name Change | 1996-02-28 | Jack R. Bevivino, M.D., Ltd. | University Plastic Surgeons, Inc. |
| Name Change | 1985-02-14 | Jack R. Bevivino, D.D.S., M.D., Ltd. | Jack R. Bevivino, M.D., Ltd. |
| Number | Name | File Date |
|---|---|---|
| 202183999430 | Articles of Dissolution | 2020-12-31 |
| 202035486420 | Annual Report | 2020-02-27 |
| 201986162160 | Annual Report | 2019-02-07 |
| 201859334320 | Annual Report | 2018-02-27 |
| 201739023780 | Annual Report | 2017-03-27 |
| 201695017100 | Annual Report | 2016-03-25 |
| 201582485500 | Statement of Change of Registered/Resident Agent | 2015-10-15 |
| 201554273870 | Annual Report | 2015-01-26 |
| 201432857420 | Annual Report | 2014-01-13 |
| 201206700480 | Annual Report | 2012-12-28 |
Date of last update: 05 Oct 2024
Sources: Rhode Island Department of State
