Basic Information
| Provider Information | |||||||||
| NPI: | 1154566735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BJA INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMPREHENSIVE SLEEP DISORDER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7005 CORTEZ RD W | ||||||||
| Address2: | 101 | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342102509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2008 | ||||||||
| LastUpdateDate: | 07/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | IBERGER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | V004V | 01 | FL | BLUE CROSS | OTHER |