Healthcare Provider Details

I. General information

NPI: 1982923330
Provider Name (Legal Business Name): BERGEN REGIONAL ANESTHESIOLOGY GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E RIDGEWOOD AVE
PARAMUS NJ
07652-4142
US

IV. Provider business mailing address

PO BOX 1258
CLIFTON NJ
07012-0758
US

V. Phone/Fax

Practice location:
  • Phone: 201-967-4000
  • Fax:
Mailing address:
  • Phone: 973-779-7361
  • Fax: 973-779-7358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25MA06850700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA06850700
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. SAM RAO
Title or Position: OFFICE MANAGER
Credential:
Phone: 973-779-7361