Healthcare Provider Details

I. General information

NPI: 1114062700
Provider Name (Legal Business Name): MARY C BERGIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 GOFFLE RD
HAWTHORNE NJ
07506-2014
US

IV. Provider business mailing address

61 W GLEN AVE
PARAMUS NJ
07652-2335
US

V. Phone/Fax

Practice location:
  • Phone: 973-427-7676
  • Fax: 973-427-7476
Mailing address:
  • Phone: 201-444-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NN07211000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: