Provider Demographics
NPI:1437282464
Name:ENGLEWOOD SURGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:ENGLEWOOD SURGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-567-0522
Mailing Address - Street 1:40 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2905
Mailing Address - Country:US
Mailing Address - Phone:201-567-0522
Mailing Address - Fax:201-567-5955
Practice Address - Street 1:40 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2905
Practice Address - Country:US
Practice Address - Phone:201-567-0522
Practice Address - Fax:201-567-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2979900Medicaid