New Jersey Department of Health

CY 2017 FINANCIAL REPORT
LICENSED AMBULATORY CARE FACILITIES
SUBJECT TO THE AMBULATORY ASSESSMENT

Refer to the accompanying instructions to fill out this form.

 

Name and Address of Facility

Dynamic Surgery Center, LLC
321 Essex Street
Hackensack, NJ 07601

License Number
24739

 

NJ Tax Identi?cation Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

81-4550655
A 
Ine Payer .
All Gross Charges Gross Recelpts 
1 Medicare (Fee-for-Service and/or HMO) 0 0 0
2 Medicaid (Fee-for?Service and/or HMO) 0 0
3 Other Government Payer 0 0 0
4 Commercial 147 9,971,328.05 1,346.14
3
5 Seif Pay 16 48,000.00 27,400.00

6 Others 1920 26.535.054.07 6,562,117.86
7 Totals 5,083 $6,554,382.12 6,590,864.00
If CY 2017 Gross Receipts are for less than 12 months, check here: 
Voluntarily Submitted Information A 
for Charity Care SEWICES All Visits Gross Charges Gross Receipts
Reduced or No?Fee Care to Patients Based Upon Ability to Pay 0 0 0

Certi?ed By (Print Name) Title
Yan Moshe if I CEO
i A
Signature i Telephone Number Date
\201-692-9800 05!03!2018
i .
Name of Licens ~lold (i differ Whom) 
Dynamicw rger] Ce nter, 
Signature Date
3 05I0312018
i? .,
HFEL-S

MAR 18