=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356159909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW JERSEY PLASTIC SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2024
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 385 ROUTE 24 STE 3K
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07930-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-879-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 385 ROUTE 24 STE 3K
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07930-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-879-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW URBAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 443-926-4937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------