Provider Demographics
NPI:1417243197
Name:WOMEN'S PELVIC SURGERY OF NORTH JERSEY, LLC
Entity Type:Organization
Organization Name:WOMEN'S PELVIC SURGERY OF NORTH JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KHASHAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKIBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-301-2772
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07451-0666
Mailing Address - Country:US
Mailing Address - Phone:201-301-2772
Mailing Address - Fax:201-882-8422
Practice Address - Street 1:1 KALISA WAY STE 103
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3508
Practice Address - Country:US
Practice Address - Phone:201-301-2772
Practice Address - Fax:201-882-8422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08288700261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty