Basic Information
| Provider Information | |||||||||
| NPI: | 1922028265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC GASTRO SURGICENTER, LLC | ||||||||
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| OtherOrganizationName: | T/A ACCESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 FIRE ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094071113 | ||||||||
| FaxNumber: | 6094077149 | ||||||||
| Practice Location | |||||||||
| Address1: | 3205 FIRE ROAD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094071113 | ||||||||
| FaxNumber: | 6094077149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | SABLYAK | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | PATRICIA | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2155899001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 22935 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7248105 | 05 | NJ | MEDICAID |