=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063031862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GANCHI PLASTIC SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2020
-----------------------------------------------------
Last Update Date | 04/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 HAMBURG TPKE STE 307
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-942-6600
-----------------------------------------------------
Fax | 973-595-5002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 246 HAMBURG TPKE STE 307
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-942-6600
-----------------------------------------------------
Fax | 973-595-5002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PARHAM GANCHI
-----------------------------------------------------
Credential | PHD, MD
-----------------------------------------------------
Telephone | 973-942-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------