Basic Information
| Provider Information | |||||||||
| NPI: | 1881633790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN STATE SURGICAL ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070805516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085619500 | ||||||||
| FaxNumber: | 9085617162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PLAINFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070805516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085619500 | ||||||||
| FaxNumber: | 9085617162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICHMAND | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9085619500 | ||||||||
| 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 | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0197712000 | 01 | NJ | AMERIHEALTH | OTHER |