1013016765 NPI number — SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013016765 NPI number — SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, 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:
1013016765
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44 NAUTILUS DR
Provider Second Line Business Mailing Address:
SUITE 2B
Provider Business Mailing Address City Name:
MANAHAWKIN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08050-2466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-597-9477
Provider Business Mailing Address Fax Number:
609-489-0226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 NAUTILUS DR
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
MANAHAWKIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08050-2466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-597-9477
Provider Business Practice Location Address Fax Number:
609-489-0226
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRACHEV
Authorized Official First Name:
SERGEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROPRIETOR
Authorized Official Telephone Number:
609-597-9477

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  25MA07937200 , 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)





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