Provider Demographics
NPI:1104949528
Name:SHORE SURGICAL ASSISTANT SERVICE, LLC
Entity type:Organization
Organization Name:SHORE SURGICAL ASSISTANT SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNFA
Authorized Official - Phone:609-476-4624
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-0331
Mailing Address - Country:US
Mailing Address - Phone:973-957-0551
Mailing Address - Fax:866-396-3054
Practice Address - Street 1:62 TUCKAHOE RD
Practice Address - Street 2:
Practice Address - City:DOROTHY
Practice Address - State:NJ
Practice Address - Zip Code:08317-9702
Practice Address - Country:US
Practice Address - Phone:609-476-4624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO09467800163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ$$$$$$$$$OtherSSN