Provider Demographics
NPI:1972556900
Name:GLEN RIDGE SURGI CENTER
Entity type:Organization
Organization Name:GLEN RIDGE SURGI CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RV
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-783-2626
Mailing Address - Street 1:230 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1529
Practice Address - Country:US
Practice Address - Phone:973-783-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ011138Medicare ID - Type Unspecified