=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912909433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTENNIAL SURGUNIT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2005
-----------------------------------------------------
Last Update Date | 08/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 CENTENNIAL BLVD SUITE 1
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-874-0790
-----------------------------------------------------
Fax | 856-751-0349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 CENTENNIAL BLVD SUITE 1
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-874-0790
-----------------------------------------------------
Fax | 856-751-0349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. STEPHEN BARAINYAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-874-0790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 22835
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------