Healthcare Provider Details

I. General information

NPI: 1134463409
Provider Name (Legal Business Name): LSA SURGERY & CONSULTATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PROSPECT ST
RIDGEWOOD NJ
07450-4493
US

IV. Provider business mailing address

145 PROSPECT ST
RIDGEWOOD NJ
07450-4493
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-4412
  • Fax:
Mailing address:
  • Phone: 201-444-4412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number25MA02025300
License Number StateNJ

VIII. Authorized Official

Name: NINO J. CARNEVALE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-444-4412