Provider Demographics
NPI:1407953698
Name:ATLANTIC SURGICAL GROUP PA
Entity Type:Organization
Organization Name:ATLANTIC SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:AVERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-531-5445
Mailing Address - Street 1:255 MONMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-1515
Mailing Address - Country:US
Mailing Address - Phone:732-531-5445
Mailing Address - Fax:732-531-0225
Practice Address - Street 1:255 MONMOUTH RD
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-1515
Practice Address - Country:US
Practice Address - Phone:732-531-5445
Practice Address - Fax:732-531-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208600000X, 208C00000X
NJ26NN09157900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ637073Medicare ID - Type Unspecified