1598700700 NPI number — SOMERSET COSMETIC & RECONSTRUCTIVE SURGERY, LLC

Table of content: (NPI 1598700700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598700700 NPI number — SOMERSET COSMETIC & RECONSTRUCTIVE SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOMERSET COSMETIC & RECONSTRUCTIVE SURGERY, 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:
Provider Other Organization Name Type Code:
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:
1598700700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 MOUNTAIN BLVD.
Provider Second Line Business Mailing Address:
BLDG T
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07059-5648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-222-0070
Provider Business Mailing Address Fax Number:
908-222-8027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 MOUNTAIN BLVD.
Provider Second Line Business Practice Location Address:
BLDG T
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07059-5648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-222-0070
Provider Business Practice Location Address Fax Number:
908-222-8027
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLOTT
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
908-222-0070

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  25MA07555400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: J33130 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: MC01512F10 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3106486 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00166342 . This is a "UNITED HEALTHCARE RR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8219869 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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