=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295824118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABJ SURGERY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 SAINT MATTHEWS AVE
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-348-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11999 SAN VICENTE BLVD STE. 440
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-5131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-440-3131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES L. PERTSCH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 650-348-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------