Healthcare Provider Details

I. General information

NPI: 1124304258
Provider Name (Legal Business Name): SURGICAL SPECIALTIES OF NEW JERSEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 WHITEHORSE MERCERVILLE RD SUITE 111
MERCERVILLE NJ
08619-3834
US

IV. Provider business mailing address

PO BOX 3204
MERCERVILLE NJ
08619-0204
US

V. Phone/Fax

Practice location:
  • Phone: 609-584-1560
  • Fax:
Mailing address:
  • Phone: 609-584-1560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MB06598500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number25MB06598500
License Number StateNJ

VIII. Authorized Official

Name: DR. BIAGIO MANNA
Title or Position: OWNER
Credential: D.O.
Phone: 609-584-1560