Healthcare Provider Details

I. General information

NPI: 1508643610
Provider Name (Legal Business Name): 787 ORTHO ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 11TH AVE
NEW YORK NY
10019-3584
US

IV. Provider business mailing address

63 COPPS HILL RD UNIT 22A
RIDGEFIELD CT
06877-4050
US

V. Phone/Fax

Practice location:
  • Phone: 475-477-5188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SARAH SANFORD
Title or Position: MEMBER MANAGER
Credential:
Phone: 212-516-8204