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General NPI Number Information
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NPI Number | 1538759394
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Entity Type | Organization
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Legal Business Name | BERGEN PHYSICAL & VEIN MEDICINE LLC
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Dates
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Enumeration Date | 01/25/2021
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 323 BERGEN BLVD
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City | FAIRVIEW
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State | NJ
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Zip | 07022-1334
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Country | US
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Telephone | 201-283-4363
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Fax | 551-264-9558
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Provider Business Mailing Address
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Address Line | 323 BERGEN BLVD
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City | FAIRVIEW
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State | NJ
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Zip | 07022-1334
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Country | US
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Telephone | 201-283-4363
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Fax | 551-264-9558
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ALEKSANDR MARTIROSOW
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Credential | MD
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Telephone | 917-450-5125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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