Healthcare Provider Details

I. General information

NPI: 1164148672
Provider Name (Legal Business Name): BRIDGECARE PROVIDER GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 BLACK OAK RIDGE RD
WAYNE NJ
07470-6501
US

IV. Provider business mailing address

173 BRIDGE PLZ N
FORT LEE NJ
07024-7575
US

V. Phone/Fax

Practice location:
  • Phone: 973-692-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. IYAD BAKER
Title or Position: OWNER
Credential:
Phone: 201-596-6262