Provider Demographics
NPI:1366449571
Name:SHORE OUTPATIENT SURGICENTER LLC
Entity Type:Organization
Organization Name:SHORE OUTPATIENT SURGICENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-609-1168
Mailing Address - Street 1:360 ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5823
Mailing Address - Country:US
Mailing Address - Phone:732-942-9835
Mailing Address - Fax:732-886-1573
Practice Address - Street 1:360 ROUTE 70
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5823
Practice Address - Country:US
Practice Address - Phone:732-942-9835
Practice Address - Fax:732-886-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22372261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7642504Medicaid
NJ490003641OtherRAILROAD MEDICARE
NJ490003641OtherRAILROAD MEDICARE
NJ31C0001099Medicare Oscar/Certification