Healthcare Provider Details

I. General information

NPI: 1881775658
Provider Name (Legal Business Name): BLAIR ALEXANDER BERGEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ENGLISH CREEK AVE BLDG 200 SUITE214
EGG HARBOR TOWNSHIP NJ
08234-5549
US

IV. Provider business mailing address

2500 ENGLISH CREEK AVE BLDG 200 SUITE214
EGG HARBOR TOWNSHIP NJ
08234-5549
US

V. Phone/Fax

Practice location:
  • Phone: 609-677-7211
  • Fax: 609-677-7210
Mailing address:
  • Phone: 609-677-7211
  • Fax: 609-677-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA04675800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: