Healthcare Provider Details

I. General information

NPI: 1558379412
Provider Name (Legal Business Name): MAIN SURGICAL CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 BROADWAY
NEWARK NJ
07104
US

IV. Provider business mailing address

PO BOX 1620
LIVINGSTON NJ
07039-7220
US

V. Phone/Fax

Practice location:
  • Phone: 973-482-8787
  • Fax: 973-484-4004
Mailing address:
  • Phone: 973-482-8787
  • Fax: 973-484-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNJ

VIII. Authorized Official

Name: NELLY BAKSHIYEV
Title or Position: MANAGER/OWNER
Credential:
Phone: 973-482-8787