Basic Information
| Provider Information | |||||||||
| NPI: | 1316020662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERGEN AMBULATORY ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34546 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071890001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019672455 | ||||||||
| FaxNumber: | 2016349647 | ||||||||
| Practice Location | |||||||||
| Address1: | 466 OLD HOOK RD | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019672455 | ||||||||
| FaxNumber: | 2016349647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AVEZZANO | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2019672455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.