1538466453 NPI number — PREMIER SURGICAL PAVILION, LLC

Table of content: (NPI 1538466453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538466453 NPI number — PREMIER SURGICAL PAVILION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER SURGICAL PAVILION, 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:
1538466453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 E 39TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10016-0943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-223-0716
Provider Business Mailing Address Fax Number:
212-223-0857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 ROSEVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07107-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-488-2101
Provider Business Practice Location Address Fax Number:
201-488-3929
Provider Enumeration Date:
02/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
212-223-0716

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  70781 , 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: 31C0001004 . This is a "CCN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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