Healthcare Provider Details

I. General information

NPI: 1346134129
Provider Name (Legal Business Name): BERGEN ORTHOPEDIC AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 KINGSLAND ST
NUTLEY NJ
07110-1119
US

IV. Provider business mailing address

495 ALLWOOD RD UNIT 4108
CLIFTON NJ
07012-6822
US

V. Phone/Fax

Practice location:
  • Phone: 973-400-1770
  • Fax:
Mailing address:
  • Phone: 973-400-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
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: MS. NEESHA N MOHAMMED
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 973-400-1770