=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922673128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOMERSET SURGICAL ASSOCIATES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 GEORGE ST STE 105
-----------------------------------------------------
City | NEW BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08901-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-725-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 REHILL AVE STE 3400
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08876-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-927-8987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | OBI J IMEGWU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-725-2400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------