Healthcare Provider Details

I. General information

NPI: 1639342686
Provider Name (Legal Business Name): INTERNAL MEDICINE ASSOCIATES OF BERGEN COUNTY P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ANDERSON ST
HACKENSACK NJ
07601-4508
US

IV. Provider business mailing address

15 ANDERSON ST
HACKENSACK NJ
07601-4508
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-3355
  • Fax: 201-487-0960
Mailing address:
  • Phone: 201-487-3355
  • Fax: 201-487-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA07441900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier527229
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerMEDICARE PROVIDER #

VIII. Authorized Official

Name: MRS. TAMMY LYNN MILLER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 201-487-3355