=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598316143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE LAPAROSCOPY ACUTE CARE SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2019
-----------------------------------------------------
Last Update Date | 09/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 POST RD STE M7
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07436-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-833-2888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17-05 GREENWOOD DR
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-4533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-873-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INCORPORATOR
-----------------------------------------------------
Name | DR. DAVID S RADVINSKY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 201-873-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------