Basic Information
| Provider Information | |||||||||
| NPI: | 1619977741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-ATLANTIC SURGICAL ASSOC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | MID-ATLANTIC SURGICAL ASSOCIATES | ||||||||
| Address2: | 100 MADISON AVENUE | ||||||||
| City: | MORRISTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739717300 | ||||||||
| FaxNumber: | 9739847019 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MADISON AVE | ||||||||
| Address2: | GAGNON LEVEL C | ||||||||
| City: | MORRISTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079606136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739717300 | ||||||||
| FaxNumber: | 9739847019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | IRVIN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9739717300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 3552501 | 05 | NJ | MEDICAID |