Provider Demographics
NPI:1013016765
Name:SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, LLC
Entity Type:Organization
Organization Name:SOUTHERN OCEAN COUNTY SURGICAL ASSOCIATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:SERGEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACHEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-597-9477
Mailing Address - Street 1:44 NAUTILUS DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2466
Mailing Address - Country:US
Mailing Address - Phone:609-597-9477
Mailing Address - Fax:609-489-0226
Practice Address - Street 1:44 NAUTILUS DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2466
Practice Address - Country:US
Practice Address - Phone:609-597-9477
Practice Address - Fax:609-489-0226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07937200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097169Medicare ID - Type UnspecifiedGROUP ID