Provider Demographics
NPI:1558379412
Name:MAIN SURGICAL CO
Entity Type:Organization
Organization Name:MAIN SURGICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKSHIYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-482-8787
Mailing Address - Street 1:PO BOX 1620
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-7220
Mailing Address - Country:US
Mailing Address - Phone:973-482-8787
Mailing Address - Fax:973-484-4004
Practice Address - Street 1:84 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-482-8787
Practice Address - Fax:973-484-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207X00000X, 224P00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0385468Medicaid
NJ0385468Medicaid