Provider Demographics
NPI:1619926946
Name:SURGICAL GROUP OF SOUTH JERSEY, P.A.
Entity Type:Organization
Organization Name:SURGICAL GROUP OF SOUTH JERSEY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIOSCORO
Authorized Official - Middle Name:T
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-428-7700
Mailing Address - Street 1:1935 ROUTE 70 E
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2117
Mailing Address - Country:US
Mailing Address - Phone:856-428-7700
Mailing Address - Fax:856-424-9120
Practice Address - Street 1:1935 ROUTE 70 E
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2117
Practice Address - Country:US
Practice Address - Phone:856-428-7700
Practice Address - Fax:856-424-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2625105Medicaid
NJ2625105Medicaid