1104105717 NPI number — BERGEN WOMEN'S AND ADOLESCENT CARE, LLC

Table of content: (NPI 1104105717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104105717 NPI number — BERGEN WOMEN'S AND ADOLESCENT CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERGEN WOMEN'S AND ADOLESCENT CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104105717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10990-8140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-688-0823
Provider Business Mailing Address Fax Number:
845-544-2201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 ESSEX ST STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-3246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
551-202-7202
Provider Business Practice Location Address Fax Number:
201-742-5328
Provider Enumeration Date:
08/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GOVINDANI
Authorized Official First Name:
NIKETA
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
MEMBER/PHYSICIAN
Authorized Official Telephone Number:
201-485-8222

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  25MA07894100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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