Healthcare Provider Details

I. General information

NPI: 1689606956
Provider Name (Legal Business Name): LIBERTY SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 JERSEY AVENUE SUITE 220
JERSEY CITY NJ
07302-4396
US

IV. Provider business mailing address

355 GRAND STREET
JERSEY CITY NJ
07302-4321
US

V. Phone/Fax

Practice location:
  • Phone: 201-309-2380
  • Fax: 201-309-2381
Mailing address:
  • Phone: 201-915-2450
  • Fax: 201-915-2192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HELEN M KENNEDY
Title or Position: CORPORATE DIRECTOR, PHYSICIAN SERVI
Credential:
Phone: 201-521-5934