Basic Information
| Provider Information | |||||||||
| NPI: | 1972531523 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BERGEN GASTROENTEROLOGY PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 466 OLD HOOK RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019678221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 466 OLD HOOK RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019678221 | ||||||||
| FaxNumber: | 2016349647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AVEZZANO | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/MD | ||||||||
| AuthorizedOfficialTelephone: | 2019678221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 465837 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.