=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417972217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROAD STREET SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1429 BROAD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-383-4150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 STATE ROUTE 35 SUITE 208
-----------------------------------------------------
City | RED BANK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07701-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-383-4159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. KENNETH NESBIHAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-383-4150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------