Healthcare Provider Details

I. General information

NPI: 1609990019
Provider Name (Legal Business Name): SPORTS MEDICINE CENTER OF BERGEN, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 MAIN ST
HACKENSACK NJ
07601-5914
US

IV. Provider business mailing address

605 MAIN ST
HACKENSACK NJ
07601-5914
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-0488
  • Fax: 201-488-5787
Mailing address:
  • Phone: 201-488-0488
  • Fax: 201-488-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. GARY FLINK
Title or Position: VICE PRESIDENT
Credential: P.T.
Phone: 201-488-0788