Provider Demographics
NPI:1417972217
Name:BROAD STREET SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:BROAD STREET SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NESBIHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-383-4150
Mailing Address - Street 1:225 STATE ROUTE 35
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5919
Mailing Address - Country:US
Mailing Address - Phone:732-383-4159
Mailing Address - Fax:
Practice Address - Street 1:1429 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4221
Practice Address - Country:US
Practice Address - Phone:732-383-4150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty