Provider Demographics
NPI:1881868263
Name:EASTERN THORACIC SURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:EASTERN THORACIC SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LOURENS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLEKES
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:732-741-9980
Mailing Address - Street 1:65 MECHANIC ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1869
Mailing Address - Country:US
Mailing Address - Phone:732-741-9980
Mailing Address - Fax:732-741-9982
Practice Address - Street 1:65 MECHANIC ST
Practice Address - Street 2:SUITE 102
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1869
Practice Address - Country:US
Practice Address - Phone:732-741-9980
Practice Address - Fax:732-741-9982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077411Medicaid
NJ085042Medicare Oscar/Certification
NJ0077411Medicaid