=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366713737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROXBURY SURGI CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2012
-----------------------------------------------------
Last Update Date | 04/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 SUNSET STRIP SUITE101
-----------------------------------------------------
City | SUCCASUNNA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-244-8100
-----------------------------------------------------
Fax | 862-244-8101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 SUNSET STRIP SUITE101
-----------------------------------------------------
City | SUCCASUNNA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-244-8100
-----------------------------------------------------
Fax | 862-244-8101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. PAUL MATYSEK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 862-244-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 22512
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------