Basic Information
| Provider Information | |||||||||
| NPI: | 1679770952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BERGEN KIDNEY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GRAND AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015675787 | ||||||||
| FaxNumber: | 2015677652 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 GRAND AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076316581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015675787 | ||||||||
| FaxNumber: | 2015677652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | PHIPPS | ||||||||
| AuthorizedOfficialFirstName: | CHARISSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6309745236 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MA057981 | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 6097201 | 05 | NJ | MEDICAID |