Healthcare Provider Details

I. General information

NPI: 1689927105
Provider Name (Legal Business Name): SHELLEY BERSON MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W GRAND AVE SUITE 500
MONTVALE NJ
07645-1813
US

IV. Provider business mailing address

305 W GRAND AVE SUITE 500
MONTVALE NJ
07645-1813
US

V. Phone/Fax

Practice location:
  • Phone: 201-391-8282
  • Fax: 201-391-8299
Mailing address:
  • Phone: 201-391-8282
  • Fax: 201-391-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number25MA05783000
License Number StateNJ

VIII. Authorized Official

Name: DR. SHELLEY BERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 201-391-8282