| Name: | University Plastic Surgeons, Inc. |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Dissolved |
| Date of Organization in Rhode Island: | 04 Oct 1983 (42 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 |
| 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. |
NAICS
621112 Offices of Physicians, Mental Health SpecialistsThis U.S. industry comprises establishments of health practitioners having the degree of M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy) primarily engaged in the independent practice of psychiatry or psychoanalysis. These practitioners operate private or group practices in their own offices (e.g., centers, clinics) or in the facilities of others, such as hospitals or HMO medical centers. Learn more at the U.S. Census Bureau
| 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 | |||||||||||||||||||||||||||||||||||||
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| 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 | |||||||||||||||||||||||||||||||
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| 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 Apr 2025
Sources: Rhode Island Department of State
