Healthcare Provider Details

I. General information

NPI: 1104914712
Provider Name (Legal Business Name): JAMES T BERGEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE 311
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 COOPER PLZ 3 DORRANCE
CAMDEN NJ
08103-1461
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2034
  • Fax: 856-342-6608
Mailing address:
  • Phone: 856-342-2034
  • Fax: 856-342-6608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMP00106
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: