Basic Information
| Provider Information | |||||||||
| NPI: | 1851470124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC SHORE SURGICAL ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 478 BRICK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087236077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327014848 | ||||||||
| FaxNumber: | 7327011244 | ||||||||
| Practice Location | |||||||||
| Address1: | 478 BRICK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087236077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327014848 | ||||||||
| FaxNumber: | 7327011244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | HAGAMAN | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7327014848 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8727503 | 05 | NJ | MEDICAID |