Basic Information
| Provider Information | |||||||||
| NPI: | 1487124368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS MEDICINE CENTER OF BERGEN, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076015914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014880488 | ||||||||
| FaxNumber: | 2013435325 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 SPRINGFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079221107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085168300 | ||||||||
| FaxNumber: | 9085168308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MGR | ||||||||
| AuthorizedOfficialTelephone: | 2014880488 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 1609990019 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.