1013921964 NPI number — BLOOMFIELD SURGI-CENTER, LLC

Table of content: (NPI 1013921964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013921964 NPI number — BLOOMFIELD SURGI-CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMFIELD SURGI-CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA AMBULATORY CENTER OF EXCELLENCE IN SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013921964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1255 BROAD STREET
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07003-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-842-2150
Provider Business Mailing Address Fax Number:
973-338-3545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 BROAD STREET
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BLOOMFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07003-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-842-2150
Provider Business Practice Location Address Fax Number:
973-338-3545
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSER
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
ARLENE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
973-842-2150

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  23459 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X , with the licence number: 23459 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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