Healthcare Provider Details

I. General information

NPI: 1275801672
Provider Name (Legal Business Name): SUBURBAN ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 BLOOMFIELD AVE SUITE 101
VERONA NJ
07044-1367
US

IV. Provider business mailing address

799 BLOOMFIELD AVE SUITE 101
VERONA NJ
07044-1367
US

V. Phone/Fax

Practice location:
  • Phone: 973-571-1600
  • Fax: 973-571-1882
Mailing address:
  • Phone: 973-571-1600
  • Fax: 973-571-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: JENETHA MORAN
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893