MEDICARE: PAVONIA SURGICAL CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396844429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAVONIA SURGICAL CENTER, LLC

Provider Business Mailing Address
First Line	:	420 MOUNTAIN AVE FL 4
Second Line	:
City	:	NEW PROVIDENCE
State	:	NJ
Zip	:	07974-2736
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 LEHIGH AVE STE 203
Second Line	:
City	:	UNION
State	:	NJ
Zip	:	07083-7631
Country	:	US
Telephone Number	:	201-216-1700
Fax Number	:

Authorized Official
Title or Position	:	VP, ASC OPERATIONS
Name	:	LAUREN A MAGNIFICO
Credential	:
Telephone Number	:	201-216-1700

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	02/05/2024

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