Provider Demographics
NPI:1538466453
Name:PREMIER SURGICAL PAVILION, LLC
Entity Type:Organization
Organization Name:PREMIER SURGICAL PAVILION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-223-0716
Mailing Address - Street 1:115 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0943
Mailing Address - Country:US
Mailing Address - Phone:212-223-0716
Mailing Address - Fax:212-223-0857
Practice Address - Street 1:145 ROSEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1618
Practice Address - Country:US
Practice Address - Phone:201-488-2101
Practice Address - Fax:201-488-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-13
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ70781261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31C0001004OtherCCN