=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699704536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH JERSEY SURGICAL ASSOCIATES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 PROSPECT ST
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-4493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-444-4412
-----------------------------------------------------
Fax | 201-444-6966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 PROSPECT STREET
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-444-4412
-----------------------------------------------------
Fax | 201-444-6966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. BETSY W. TYRAS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 201-444-4412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA01903
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------