Healthcare Provider Details

I. General information

NPI: 1104105717
Provider Name (Legal Business Name): BERGEN WOMEN'S AND ADOLESCENT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 ESSEX ST STE 301
HACKENSACK NJ
07601-3246
US

IV. Provider business mailing address

PO BOX 1140
WARWICK NY
10990-8140
US

V. Phone/Fax

Practice location:
  • Phone: 551-202-7202
  • Fax: 201-742-5328
Mailing address:
  • Phone: 201-688-0823
  • Fax: 845-544-2201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA07894100
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: NIKETA V. GOVINDANI
Title or Position: MEMBER/PHYSICIAN
Credential: MD
Phone: 201-485-8222