Provider Demographics
NPI:1396844429
Name:PAVONIA SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:PAVONIA SURGICAL CENTER, LLC
Other - Org Name:PRISM SURGERY CENTER AT UNION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, ASC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAGNIFICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-216-1700
Mailing Address - Street 1:420 MOUNTAIN AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-2736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 LEHIGH AVE STE 203
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7631
Practice Address - Country:US
Practice Address - Phone:201-216-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ52773021Medicaid
NJ52773021Medicaid