Healthcare Provider Details

I. General information

NPI: 1447468475
Provider Name (Legal Business Name): BERGEN MEDICAL CENTER MULTI SPECIALTY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W RIDGEWOOD AVE G3
PARAMUS NJ
07652-2359
US

IV. Provider business mailing address

1 W RIDGEWOOD AVE G3
PARAMUS NJ
07652-2359
US

V. Phone/Fax

Practice location:
  • Phone: 201-262-8274
  • Fax: 201-262-8718
Mailing address:
  • Phone: 201-262-8274
  • Fax: 201-262-8718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMA49009
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JEFFREY ALLEN SHANTON
Title or Position: ADMIN
Credential:
Phone: 201-262-8274