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General NPI Number Information
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NPI Number | 1013016765
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Entity Type | Organization
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Legal Business Name | SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, LLC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 44 NAUTILUS DR SUITE 2B
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City | MANAHAWKIN
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State | NJ
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Zip | 08050-2466
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Country | US
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Telephone | 609-597-9477
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Fax | 609-489-0226
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Provider Business Mailing Address
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Address Line | 44 NAUTILUS DR SUITE 2B
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City | MANAHAWKIN
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State | NJ
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Zip | 08050-2466
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Country | US
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Telephone | 609-597-9477
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Fax | 609-489-0226
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Authorized Official
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Title or Position | PROPRIETOR
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Name | SERGEY GRACHEV
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Credential | M.D.
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Telephone | 609-597-9477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 25MA07937200
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License Number State | NJ
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