Provider Demographics
NPI:1134463409
Name:LSA SURGERY & CONSULTATION PC
Entity Type:Organization
Organization Name:LSA SURGERY & CONSULTATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NINO
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARNEVALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-444-4412
Mailing Address - Street 1:145 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4493
Mailing Address - Country:US
Mailing Address - Phone:201-444-4412
Mailing Address - Fax:
Practice Address - Street 1:145 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4493
Practice Address - Country:US
Practice Address - Phone:201-444-4412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02025300261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ023599OtherMEDICARE PTAN