Healthcare Provider Details

I. General information

NPI: 1912459348
Provider Name (Legal Business Name): HERITAGE GENERAL AND COLORECTAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 TEANECK RD SUITE B
TEANECK NJ
07666-4243
US

IV. Provider business mailing address

741 TEANECK RD SUITE B
TEANECK NJ
07666-4243
US

V. Phone/Fax

Practice location:
  • Phone: 201-833-2888
  • Fax:
Mailing address:
  • Phone: 201-833-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. FARSHAD MANSOURI
Title or Position: PRESIDENT
Credential:
Phone: 716-523-7930