Provider Demographics
NPI:1508891417
Name:MID ATLANTIC MULTI SPECIALTY SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:MID ATLANTIC MULTI SPECIALTY SURGICAL GROUP, LLC
Other - Org Name:MAMSURG
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-597-4112
Mailing Address - Street 1:2356 US HIGHWAY 9
Mailing Address - Street 2:SUITE B6
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-4017
Mailing Address - Country:US
Mailing Address - Phone:732-886-2252
Mailing Address - Fax:732-886-2260
Practice Address - Street 1:2356 US HIGHWAY 9
Practice Address - Street 2:SUITE B6
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-4017
Practice Address - Country:US
Practice Address - Phone:732-886-2252
Practice Address - Fax:732-886-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD06277OtherRAIL ROAD MEDICARE
NJ107270Medicare PIN