Healthcare Provider Details

I. General information

NPI: 1639561293
Provider Name (Legal Business Name): MULBERRY AMBULATORY SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393-397 MULBERRY STREET
NEWARK NJ
07012-3417
US

IV. Provider business mailing address

PO BOX 9425
NEW YORK NY
10087-9425
US

V. Phone/Fax

Practice location:
  • Phone: 929-400-2159
  • Fax:
Mailing address:
  • Phone: 212-874-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number25MA07669400
License Number StateNJ

VIII. Authorized Official

Name: DR. DOMENICA M BARRITTA
Title or Position: OWNER/ DIRECTOR
Credential: M.D.
Phone: 929-400-2159