Provider Demographics
NPI:1801177787
Name:MANSURG LLC
Entity type:Organization
Organization Name:MANSURG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICE
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-778-0100
Mailing Address - Street 1:1360 CLIFTON AVE
Mailing Address - Street 2:#330
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1343
Mailing Address - Country:US
Mailing Address - Phone:973-778-0100
Mailing Address - Fax:973-778-2029
Practice Address - Street 1:1100 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3631
Practice Address - Country:US
Practice Address - Phone:973-778-0100
Practice Address - Fax:973-778-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08977300208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty