Provider Demographics
NPI:1073284675
Name:NEW JERSEY PLASTIC SURGERY
Entity Type:Organization
Organization Name:NEW JERSEY PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-509-2000
Mailing Address - Street 1:29 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3407
Mailing Address - Country:US
Mailing Address - Phone:973-509-2000
Mailing Address - Fax:
Practice Address - Street 1:29 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3407
Practice Address - Country:US
Practice Address - Phone:973-509-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1427342971Medicaid
NJ1942563564Medicaid
NJ1164599262Medicaid