Basic Information
Provider Information | |||||||||
NPI: | 1457698805 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SURGERY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SURGERY SERVICES, LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4059 | ||||||||
Address2: |   | ||||||||
City: | WAYNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 074744059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738261540 | ||||||||
FaxNumber: | 8558345435 | ||||||||
Practice Location | |||||||||
Address1: | 504 VALLEY RD | ||||||||
Address2: | SUITE 201 | ||||||||
City: | WAYNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 074703534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738268540 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2013 | ||||||||
LastUpdateDate: | 01/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILSON | ||||||||
AuthorizedOfficialFirstName: | CAREEN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | MANGER | ||||||||
AuthorizedOfficialTelephone: | 9738941263 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.