MEDICARE: SHORE SURGICAL ASSISTANT SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	26NO09467800	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	$$$$$$$$$	OTHER	NJ	SSN

General Provider Information

NPI Number	:	1104949528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORE SURGICAL ASSISTANT SERVICE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 331
Second Line	:
City	:	MAYS LANDING
State	:	NJ
Zip	:	08330-0331
Country	:	US
Telephone Number	:	973-957-0551
Fax Number	:	866-396-3054

Provider Business Practice Location Address
First Line	:	62 TUCKAHOE RD
Second Line	:
City	:	DOROTHY
State	:	NJ
Zip	:	08317-9702
Country	:	US
Telephone Number	:	609-476-4624
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GARY A BUCK
Credential	:	CRNFA
Telephone Number	:	609-476-4624

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	05/21/2020

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