Basic Information
| Provider Information | |||||||||
| NPI: | 1134513260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN AVENUE CLIFTON SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 THROCKMORTON LN | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | OLD BRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088572520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329525533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1084 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070112330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734734040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 03/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | POONIA | ||||||||
| AuthorizedOfficialFirstName: | AMIT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7329525533 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.