Basic Information
| Provider Information | |||||||||
| NPI: | 1336446863 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN STATE MEDICAL AND SURGICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 LEMOINE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070245622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014616666 | ||||||||
| FaxNumber: | 2014617429 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 LEMOINE AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070245622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014616666 | ||||||||
| FaxNumber: | 2014617429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2011 | ||||||||
| LastUpdateDate: | 02/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2014616666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA05840700 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.