Provider Demographics
NPI:1922075969
Name:SAINT MARY'S AMBULATORY SURGERY
Entity Type:Organization
Organization Name:SAINT MARY'S AMBULATORY SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-585-2911
Mailing Address - Street 1:540 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2322
Mailing Address - Country:US
Mailing Address - Phone:201-585-2911
Mailing Address - Fax:201-585-2977
Practice Address - Street 1:540 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650
Practice Address - Country:US
Practice Address - Phone:201-585-2911
Practice Address - Fax:201-585-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ311186OtherHORIZON BCBS
GA2628993OtherUNITED HEALTHCARE
NJ0084361Medicaid
CTA3608737OtherOXFORD
NJ311186OtherHORIZON BCBS
NJ0084361Medicaid